MEDICARE: FORWARD PSYCHOLOGY GROUP, LLC

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	103TC0700X	Clinical Psychologist	1715	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	$$$$$$$$$	OTHER		SSN

General Provider Information

NPI Number	:	1336362946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORWARD PSYCHOLOGY GROUP, LLC

Provider Business Mailing Address
First Line	:	478 COMMERCE DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-4993
Country	:	US
Telephone Number	:	608-833-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	478 COMMERCE DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-4993
Country	:	US
Telephone Number	:	608-833-7533
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. GORDON I HERZ
Credential	:	PHD
Telephone Number	:	608-833-7533

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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