Provider Demographics
NPI:1083253520
Name:MCCORMICK, SHAKA D (LMT)
Entity Type:Individual
Prefix:MS
First Name:SHAKA
Middle Name:D
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27041
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-0041
Mailing Address - Country:US
Mailing Address - Phone:618-918-1245
Mailing Address - Fax:
Practice Address - Street 1:2804 OSAGE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4537
Practice Address - Country:US
Practice Address - Phone:314-448-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-01
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019000899225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist