MEDICARE: MR. VERNON WAYNE FORMAN CERTIFICATIONS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1701	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1701	OTHER	WI	CERT. AODA COUNSELOR III
2	11482	OTHER	WI	CERT. CLIN. SUPERVISOR II

General Provider Information

NPI Number	:	1952403966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VERNON WAYNE FORMAN CERTIFICATIONS

Provider Business Mailing Address
First Line	:	722 S SPRING ST
Second Line	:
City	:	PORT WASHINGTON
State	:	WI
Zip	:	53074-2334
Country	:	US
Telephone Number	:	262-483-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	722 S SPRING ST
Second Line	:
City	:	PORT WASHINGTON
State	:	WI
Zip	:	53074-2334
Country	:	US
Telephone Number	:	262-483-0048
Fax Number	:

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	03/08/2026

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