Healthcare Provider Details

I. General information

NPI: 1447538269
Provider Name (Legal Business Name): KATRINA FORMAN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 04/14/2023
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 HOLLYWOOD BLVD # 127
HOLLYWOOD FL
33021-6635
US

IV. Provider business mailing address

4302 HOLLYWOOD BLVD STE 127
HOLLYWOOD FL
33021-6635
US

V. Phone/Fax

Practice location:
  • Phone: 954-505-0554
  • Fax: 954-505-0554
Mailing address:
  • Phone: 954-505-0554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: