Provider Demographics
NPI:1316113970
Name:DAVID FORMWALT, PSY.D., LLC
Entity type:Organization
Organization Name:DAVID FORMWALT, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORMWALT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:251-776-1217
Mailing Address - Street 1:PO BOX 91276
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36691-1276
Mailing Address - Country:US
Mailing Address - Phone:251-776-1217
Mailing Address - Fax:
Practice Address - Street 1:7305 COTTAGE HILL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-2829
Practice Address - Country:US
Practice Address - Phone:251-776-1217
Practice Address - Fax:251-776-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1104103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000098829Medicare UPIN