Provider Demographics
NPI:1477072957
Name:MCCORMACK, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2508
Mailing Address - Country:US
Mailing Address - Phone:216-361-4400
Mailing Address - Fax:216-361-2340
Practice Address - Street 1:3134 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2508
Practice Address - Country:US
Practice Address - Phone:216-361-9100
Practice Address - Fax:216-361-7774
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1700427104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker