Provider Demographics
NPI:1164552998
Name:MCCORMICK, KELLY (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1535
Mailing Address - Country:US
Mailing Address - Phone:503-233-6141
Mailing Address - Fax:503-233-2889
Practice Address - Street 1:1939 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1535
Practice Address - Country:US
Practice Address - Phone:503-233-6141
Practice Address - Fax:503-233-2889
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-353618237700000X
WAHA00002483237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist