Healthcare Provider Details

I. General information

NPI: 1164837340
Provider Name (Legal Business Name): SHERRY R FORZLEY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 MIDDLEBURY ST
GOSHEN IN
46528-2739
US

IV. Provider business mailing address

2314 MIAMI ST
SOUTH BEND IN
46614-1336
US

V. Phone/Fax

Practice location:
  • Phone: 574-383-0107
  • Fax: 877-804-8654
Mailing address:
  • Phone: 574-234-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-21690
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: