| Doctor Name: | LISA L. FORMAN |
| NPI Number: | 1275768756 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW, PIP |
| License Number: | 0910-2189C |
| Business Practice Address: | 3480 Broad St Phil Campbell, AL - 355813600 |
| Business Phone Number: | 2059934556 |
| Business Fax Number: | 2059934556 |
| Mailing Address: | 3480 Broad St, PHIL CAMPBELL |
| State: | AL |
| Postal Code: | 355813600 |
| Phone Number: | 2059934556 |
| Fax Number: | |
| NPI Enumeration Date: | 05/27/2009 |
| NPI Last Update Date: | 09/10/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 0910-2189C |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |