MEDICARE: KAITLEN FORMAN LPC, M.S., NCC

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	101YP2500X	Professional Counselor	75642	TX

General Provider Information

NPI Number	:	1396382826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLEN FORMAN LPC, M.S., NCC

Provider Business Mailing Address
First Line	:	PO BOX 1618
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75034-0027
Country	:	US
Telephone Number	:	469-892-8842
Fax Number	:

Provider Business Practice Location Address
First Line	:	8400 STACY RD STE 100
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75070-2144
Country	:	US
Telephone Number	:	469-892-8842
Fax Number	:

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

Provider Enumeration Date	:	12/03/2019
Last Update Date	:	08/08/2022

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