Provider Demographics
NPI:1225164585
Name:MCCORMICK, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2853
Mailing Address - Country:US
Mailing Address - Phone:510-205-6854
Mailing Address - Fax:707-981-7919
Practice Address - Street 1:6 PETALUMA BLVD N
Practice Address - Street 2:SUITE B4
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3050
Practice Address - Country:US
Practice Address - Phone:510-205-6854
Practice Address - Fax:707-981-7919
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical