Provider Demographics
NPI:1164247847
Name:FORGANG, ILLESE (LCSW)
Entity type:Individual
Prefix:
First Name:ILLESE
Middle Name:
Last Name:FORGANG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SEAVIEW AVE
Mailing Address - Street 2:SUITE 4E
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06855-2305
Mailing Address - Country:US
Mailing Address - Phone:203-293-8215
Mailing Address - Fax:
Practice Address - Street 1:100 SEAVIEW AVE
Practice Address - Street 2:SUITE 4E
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06855-2305
Practice Address - Country:US
Practice Address - Phone:203-293-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT145011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical