Basic Information
| Provider Information | |||||||||
| NPI: | 1578532438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | ELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5700 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664314077 | ||||||||
| FaxNumber: | 4137747448 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 MAIN ST | ||||||||
| Address2: | NORTHAMPTON HEALTH CENTER | ||||||||
| City: | FLORENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010621466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135868400 | ||||||||
| FaxNumber: | 4135855491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1031672 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 102517 | 01 | MA | FALLON | OTHER | 3172516 | 01 | MA | CIGNA BEHAVIORAL HEALTH | OTHER | 468597 | 01 | MA | TUFTS HEALTH PLAN | OTHER | P07575 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 33214 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 593372000 | 01 | MA | MAGELLAN BEHAVIORAL HEALT | OTHER |