Provider Demographics
NPI:1447538269
Name:FORMAN, KATRINA (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 HOLLYWOOD BLVD STE 127
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6635
Mailing Address - Country:US
Mailing Address - Phone:954-505-0554
Mailing Address - Fax:
Practice Address - Street 1:4302 HOLLYWOOD BLVD # 127
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6635
Practice Address - Country:US
Practice Address - Phone:954-505-0554
Practice Address - Fax:954-505-0554
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 103K00000X, 251S00000X
FL104100000X
FLSW178811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health