Provider Demographics
NPI:1003879206
Name:CORMICAN, THOMAS J (LICSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:CORMICAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LEDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GONIC
Mailing Address - State:NH
Mailing Address - Zip Code:03839-5619
Mailing Address - Country:US
Mailing Address - Phone:603-817-5075
Mailing Address - Fax:
Practice Address - Street 1:20 LEDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03839-5619
Practice Address - Country:US
Practice Address - Phone:603-923-8836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2274101YA0400X
NH17451041C0700X
MA1151741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)