Provider Demographics
NPI:1497153308
Name:MCCORMACK, MEGAN (PMHNP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BROG RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12748-5100
Mailing Address - Country:US
Mailing Address - Phone:845-701-6160
Mailing Address - Fax:
Practice Address - Street 1:3824 NY-17M
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:10958
Practice Address - Country:US
Practice Address - Phone:845-374-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY637111163W00000X
NY402745363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse