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General NPI Number Information
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NPI Number | 1164591541
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Entity Type | Individual
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Provider Name | DAVID FORMWALT PSY D
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Gender | Male
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 7305 COTTAGE HILL ROAD
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City | MOBILE
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State | AL
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Zip | 36695
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Country | US
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Telephone | 251-776-1217
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Fax | 251-776-1219
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Provider Business Mailing Address
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Address Line | POB 91276 DAVID FORMWALT PSY D LLC
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City | MOBILE
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State | AL
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Zip | 36691
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Country | US
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Telephone | 251-776-1217
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Fax | 251-776-1219
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1104
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License Number State | AL
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