Provider Demographics
NPI:1972321180
Name:FORSMAN, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:FORSMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-4029
Mailing Address - Country:US
Mailing Address - Phone:240-291-1436
Mailing Address - Fax:
Practice Address - Street 1:5419 DEALE CHURCHTON RD STE 104
Practice Address - Street 2:
Practice Address - City:CHURCHTON
Practice Address - State:MD
Practice Address - Zip Code:20733-2408
Practice Address - Country:US
Practice Address - Phone:410-541-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15666101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor