Provider Demographics
NPI:1376064964
Name:MCCORMACK, KELLY BURNS (ATR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BURNS
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 TRUMP RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-9375
Mailing Address - Country:US
Mailing Address - Phone:570-412-5106
Mailing Address - Fax:
Practice Address - Street 1:435 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6001
Practice Address - Country:US
Practice Address - Phone:570-322-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist