Healthcare Provider Details

I. General information

NPI: 1003720590
Provider Name (Legal Business Name): ANGIE FORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 4TH AVE SE
DECATUR AL
35601-4904
US

IV. Provider business mailing address

1608 4TH AVE SE
DECATUR AL
35601-4904
US

V. Phone/Fax

Practice location:
  • Phone: 256-340-9233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberALC05880
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: