ANNE MARIE FORMAN Social Worker License verification

Business Entity

INACTIVE

License Type

Social Worker

Description

LICENSED CLINICAL SOCIAL WORKER

License Number

149003275

License Status

INACTIVE

Business

First Name

ANNE MARIE

Last Name

FORMAN

Business Name

ANNE MARIE FORMAN

Original Issue Date

03/29/1991

Effective Date

11/14/2003

Expiration Date

11/30/2003

City

PORT WASHINGTON

State

Zip

53074

County

WISCONSIN

Specialty/Qualifier

MASTERS

Ever Disciplined

LastModifiedDate

12/16/2005