Provider Demographics
NPI:1144227356
Name:MCCORMACK, TANYA MARIE (AUD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:MARIE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 MADISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4914
Mailing Address - Country:US
Mailing Address - Phone:636-390-6020
Mailing Address - Fax:636-390-6021
Practice Address - Street 1:1713 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4914
Practice Address - Country:US
Practice Address - Phone:636-390-6020
Practice Address - Fax:636-390-6021
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004015328231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1144227356Medicaid
MOP01152556OtherRAILROAD MEDICARE
P00461427OtherRAILROAD MEDICARE
P00461427OtherRAILROAD MEDICARE
MOMA4217002Medicare PIN