Provider Demographics
NPI:1962190637
Name:FORMAN, KARYN BETH (LAC)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:BETH
Last Name:FORMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 GREY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1508
Mailing Address - Country:US
Mailing Address - Phone:312-203-2667
Mailing Address - Fax:
Practice Address - Street 1:2225 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5429
Practice Address - Country:US
Practice Address - Phone:312-203-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000582171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist