Provider Demographics
NPI:1477060135
Name:MCCORMACK, ELIZABETH DEBRA (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DEBRA
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3638
Mailing Address - Country:US
Mailing Address - Phone:708-603-3026
Mailing Address - Fax:
Practice Address - Street 1:818 10TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3638
Practice Address - Country:US
Practice Address - Phone:708-603-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer