Provider Demographics
NPI:1417219700
Name:MCCORMACK, LAURA MARIE (MSED)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:PANDOLFI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSED
Mailing Address - Street 1:114 CLAYPIT RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1902
Mailing Address - Country:US
Mailing Address - Phone:718-967-1806
Mailing Address - Fax:
Practice Address - Street 1:114 CLAYPIT RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1902
Practice Address - Country:US
Practice Address - Phone:718-967-1806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist