Healthcare Provider Details

I. General information

NPI: 1285684456
Provider Name (Legal Business Name): GORDON M. FORWARD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 MEDICAL CENTER PKWY
SELMA AL
36701-6780
US

IV. Provider business mailing address

PO BOX 681628
PRATTVILLE AL
36068-1628
US

V. Phone/Fax

Practice location:
  • Phone: 334-875-2100
  • Fax: 334-418-6540
Mailing address:
  • Phone: 334-875-2100
  • Fax: 334-418-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number265C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: