Emily Jeanne Fornwalt, LCMHC-S

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

S6459 Issued in NC

Practice address

614 W Pine St
Johnson City, TN 37604-6608

Phone

(423) 281-4089

NPI assigned

Mar 8, 2007

Last updated

May 1, 2024By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Apr 22, 2024 through Apr 22, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• United Family Services

  • Community/Behavioral Health Agency
  • Monroe, NC
  • NPI 1558485011
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173312000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1714521600000",
    "number": "1083745434",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "614 W PINE ST",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376046608",
            "telephone_number": "423-281-4089"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "614 W PINE ST",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376046608",
            "telephone_number": "423-281-4089"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FORNWALT",
        "first_name": "EMILY",
        "middle_name": "JEANNE",
        "credential": "LCMHC-S",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-03-08",
        "last_updated": "2024-05-01",
        "certification_date": "2024-05-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NC",
            "license": "S6459",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Timothy Aaron Ford, DO
• Forest Path Therapy Group LLC
• Forester Clinic, P.C.
• David Lionel Forester, M.D.
• Rachel Forlow
• Sheila Walters Forrester, PHARMD
• Mary Rachel Forslin, BS
• Brittany Foster
• Daniel Foster, DPT
• Joshua T Foster, CRNA

• Mental Health Counselor in Johnson City, TN
• Providers in Johnson City, TN by specialty
• Mental Health Counselor in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.