Individual
MINDY FORMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSYD
Contact information
Practice address
1248 AMERICAN WAY, LIBERTYVILLE, IL 60048-3936
(224) 433-6744
Mailing address
1248 AMERICAN WAY, LIBERTYVILLE, IL 60048-3936
(224) 433-6744
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
103T00000X
Psychologist
Primary
071.009917
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1851768725
—
IL
Enumeration date
08/27/2015
Last updated
12/13/2018
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