MEDICARE: MS. MAUREEN HARRIS FORMAN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS14661	CA

General Provider Information

NPI Number	:	1023395514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MAUREEN HARRIS FORMAN LCSW

Provider Business Mailing Address
First Line	:	73875 KRUG AVE
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-9320
Country	:	US
Telephone Number	:	760-895-8610
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 S FARRELL DR
Second Line	:	SUITE C 208
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-7992
Country	:	US
Telephone Number	:	760-325-4088
Fax Number	:	760-778-3781

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	01/17/2019

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