Healthcare Provider Details

I. General information

NPI: 1104433234
Provider Name (Legal Business Name): HELEN ELIZABETH FORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 WASHINGTON HWY
ASHLAND VA
23005-7646
US

IV. Provider business mailing address

12300 WASHINGTON HWY
ASHLAND VA
23005-7646
US

V. Phone/Fax

Practice location:
  • Phone: 804-365-4222
  • Fax: 804-365-4252
Mailing address:
  • Phone: 804-365-4222
  • Fax: 804-365-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701009604
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: