Provider Demographics
NPI:1154820405
Name:FORMAN, KARLIE MICHELLE (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:KARLIE
Middle Name:MICHELLE
Last Name:FORMAN
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 WILLIS PL
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-1227
Mailing Address - Country:US
Mailing Address - Phone:601-882-4690
Mailing Address - Fax:
Practice Address - Street 1:716 WILLIS PL
Practice Address - Street 2:
Practice Address - City:ROSELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07204-1227
Practice Address - Country:US
Practice Address - Phone:601-882-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1-17-27164103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst