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NPI Code Detail

MEDICARE: GABRIELLE J. FORMAN L.C.S.W.

MEDICARE: GABRIELLE J. FORMAN L.C.S.W.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social WorkerLCS 24101CA

General Provider Information

NPI Number : 1073746681
Entity Type Code : Individual
Provider Name (Legal Business Name) : GABRIELLE J. FORMAN L.C.S.W.
Provider Business Mailing Address
First Line : 3507 MADERA AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90039-1929
Country : US
Telephone Number : 310-625-2102
Fax Number :
Provider Business Practice Location Address
First Line : 2904 ROWENA AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90039-2042
Country : US
Telephone Number : 310-625-2102
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2009
Last Update Date : 08/30/2009

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