Provider Demographics
NPI:1275129264
Name:MCCORMACK, ANTONIO LYNE
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:LYNE
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 REGENCY WAY APT 1
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-7134
Mailing Address - Country:US
Mailing Address - Phone:270-307-4252
Mailing Address - Fax:
Practice Address - Street 1:107 CRANES ROOST CT
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3650
Practice Address - Country:US
Practice Address - Phone:270-765-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor