Provider Demographics
NPI:1386687838
Name:MCCORMACK, JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:MCCORMACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2756 COUNTY ROAD 338
Mailing Address - Street 2:
Mailing Address - City:NEW BLOOMFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65063-1147
Mailing Address - Country:US
Mailing Address - Phone:573-491-3431
Mailing Address - Fax:573-761-6888
Practice Address - Street 1:3702 W TRUMAN BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4970
Practice Address - Country:US
Practice Address - Phone:573-634-5303
Practice Address - Fax:573-761-6888
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01327103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR00832Medicare UPIN