Provider Demographics
NPI:1235290560
Name:MCCORMICK, MAUREEN KELLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:KELLY
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MAUREEN (BETSY)
Other - Middle Name:KELLY
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:26 PLAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778
Mailing Address - Country:US
Mailing Address - Phone:508-358-6366
Mailing Address - Fax:
Practice Address - Street 1:592A WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-6417
Practice Address - Country:US
Practice Address - Phone:508-736-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2020-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6334103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05172OtherBL