1124256060 NPI number — TONI LYN MARINKOVICH FORMAN LPC

Table of content: TONI LYN MARINKOVICH FORMAN LPC (NPI 1124256060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124256060 NPI number — TONI LYN MARINKOVICH FORMAN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMAN
Provider First Name:
TONI
Provider Middle Name:
LYN MARINKOVICH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARINKOVICH
Provider Other First Name:
TONI
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124256060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 DIXON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80026-8879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-443-8500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1333 IRIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80304-2226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-413-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)