1114187655 NPI number — MS. TONDA L FORMAN LPCC

Table of content: MS. TONDA L FORMAN LPCC (NPI 1114187655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114187655 NPI number — MS. TONDA L FORMAN LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMAN
Provider First Name:
TONDA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114187655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1351 NEWTOWN PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40511-1217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-253-1686
Provider Business Mailing Address Fax Number:
859-254-2743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 SOUTHVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICHOLASVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40356-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-253-1686
Provider Business Practice Location Address Fax Number:
859-254-2743
Provider Enumeration Date:
06/09/2008

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: 101YP2500X , with the licence number:  0823 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790731081 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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