Provider Demographics
NPI:1427721836
Name:FORMAN, ALISA
Entity type:Individual
Prefix:MS
First Name:ALISA
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ALISA
Other - Middle Name:
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 HENDRICKSON CT
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-7900
Mailing Address - Country:US
Mailing Address - Phone:732-456-3399
Mailing Address - Fax:732-414-1825
Practice Address - Street 1:15 HENDRICKSON CT
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-7900
Practice Address - Country:US
Practice Address - Phone:732-456-3399
Practice Address - Fax:732-414-1825
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool