MEDICARE: MOZELLE FORMAN

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
2	1041C0700X	Clinical Social Worker	053989	NY

General Provider Information

NPI Number	:	1710493416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOZELLE FORMAN

Provider Business Mailing Address
First Line	:	1172 ELBERON AVE
Second Line	:
City	:	LONG BRANCH
State	:	NJ
Zip	:	07740-4506
Country	:	US
Telephone Number	:	732-668-2187
Fax Number	:

Provider Business Practice Location Address
First Line	:	1138 E 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-4704
Country	:	US
Telephone Number	:	732-668-2187
Fax Number	:

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

Provider Enumeration Date	:	12/18/2017
Last Update Date	:	12/18/2017

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Directions to “ MOZELLE FORMAN ” Practice Location

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