Provider Demographics
NPI:1114090495
Name:MCCORMICK, MELISSA N (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:N
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12945 W CRITTENDEN LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6686
Mailing Address - Country:US
Mailing Address - Phone:623-376-9100
Mailing Address - Fax:623-376-9141
Practice Address - Street 1:7707 W DEER VALLEY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2101
Practice Address - Country:US
Practice Address - Phone:623-376-9100
Practice Address - Fax:623-376-9100
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist