Provider Demographics
NPI:1083001622
Name:MCCORMICK, KYLIE (MS, MFT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 HANLEY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8786
Mailing Address - Country:US
Mailing Address - Phone:534-544-5247
Mailing Address - Fax:
Practice Address - Street 1:2501 HANLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8786
Practice Address - Country:US
Practice Address - Phone:534-544-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1097-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13546470Medicaid