=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841254950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN M FORMAN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2006
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 RITTENHOUSE SQ APT 1204
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-5818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-650-7449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 623 REVERE RD
-----------------------------------------------------
City | MERION STATION
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19066-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-650-7449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS 015133
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------