Healthcare Provider Details

I. General information

NPI: 1558612853
Provider Name (Legal Business Name): ALEXANDREA JOSEPHINE FORWARD LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 LAKE ST
BURLINGTON VT
05401-5297
US

IV. Provider business mailing address

180 ETHAN ALLEN PKWY
BURLINGTON VT
05408-2523
US

V. Phone/Fax

Practice location:
  • Phone: 802-865-3450
  • Fax:
Mailing address:
  • Phone: 917-208-5024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number089.0128888
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number089.0128888
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: