Provider Demographics
NPI:1215001680
Name:MCCORMICK, PAUL GLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:GLEN
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:GLEN
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:271 MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3591
Mailing Address - Country:US
Mailing Address - Phone:781-438-5550
Mailing Address - Fax:781-438-5553
Practice Address - Street 1:271 MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3591
Practice Address - Country:US
Practice Address - Phone:781-438-5550
Practice Address - Fax:781-438-5553
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4192103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1899236Medicaid
MA1899236Medicaid