Provider Demographics
NPI:1861607814
Name:FORMAN, ELLEN SARI (PHD,LCAT,LMHC,CASAC,)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:SARI
Last Name:FORMAN
Suffix:
Gender:F
Credentials:PHD,LCAT,LMHC,CASAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E ALLEN ST
Mailing Address - Street 2:#7
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2423
Mailing Address - Country:US
Mailing Address - Phone:518-828-7400
Mailing Address - Fax:518-329-1752
Practice Address - Street 1:430 E ALLEN ST
Practice Address - Street 2:#7
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2423
Practice Address - Country:US
Practice Address - Phone:518-828-7400
Practice Address - Fax:518-329-1752
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2009-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002589101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000412063001OtherBLUE SHIELD OF NE NY