Doctor Name: | DR. ELI MICHAEL SIMONG FORMAN |
NPI Number: | 1033218714 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PHD |
License Number: | 5688633 |
Business Practice Address: | 431 Park Avenue Leonia, NJ - 076051219 |
Business Phone Number: | 2015927388 |
Business Fax Number: | 2015926301 |
Mailing Address: | 431 Park Avenue, LEONIA |
State: | NJ |
Postal Code: | 076051219 |
Phone Number: | 2015927388 |
Fax Number: | 2015926301 |
NPI Enumeration Date: | 09/21/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 5688633 |
Healthcare Provider Taxonomy: (Secondary) | X |
State: | NY |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |