Provider Demographics
NPI:1164876793
Name:MCCORMICK, KITTY
Entity Type:Individual
Prefix:
First Name:KITTY
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1907
Mailing Address - Country:US
Mailing Address - Phone:323-336-4782
Mailing Address - Fax:
Practice Address - Street 1:547 S MARENGO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3114
Practice Address - Country:US
Practice Address - Phone:323-336-4782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical