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General NPI Number Information
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NPI Number | 1316243314
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Entity Type | Organization
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Legal Business Name | JODY FORMAN, MSW, L.AC., PLLC
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Dates
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Enumeration Date | 02/08/2011
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Last Update Date | 02/08/2011
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Provider Practice Location Address
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Address Line | 355 WEST RIO RD SUITE 206A
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-1362
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Country | US
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Telephone | 434-975-0025
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Fax |
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Provider Business Mailing Address
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Address Line | 355 WEST RIO RD SUITE 206A
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-1362
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Country | US
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Telephone | 434-975-0025
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Fax |
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Authorized Official
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Title or Position | LICENSED ACUPUNCTURIST
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Name | MS. JODY FORMAN
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Credential | MSW.,L.AC., PLLC
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Telephone | 434-975-0025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 0121000011
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License Number State | VA
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