Healthcare Provider Details

I. General information

NPI: 1790865301
Provider Name (Legal Business Name): MARJORIE FORMAN LCSW LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 39TH ST SUITE 808
NEW YORK NY
10016-0933
US

IV. Provider business mailing address

150 E 39TH ST SUITE 808
NEW YORK NY
10016-0933
US

V. Phone/Fax

Practice location:
  • Phone: 212-779-0462
  • Fax: 631-287-6346
Mailing address:
  • Phone: 212-779-0462
  • Fax: 631-287-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR021152
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number000232-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: