Provider Demographics
NPI:1376571729
Name:MCCORMACK, DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 BELANGER ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3334
Mailing Address - Country:US
Mailing Address - Phone:313-885-1385
Mailing Address - Fax:313-884-6432
Practice Address - Street 1:366 BELANGER ST
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3334
Practice Address - Country:US
Practice Address - Phone:313-885-1385
Practice Address - Fax:313-884-6432
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H247980OtherBCBSM
MI0M33370Medicare ID - Type Unspecified