Provider Demographics
NPI:1497958557
Name:CORMACK, ELIZABETH MARY (OTR L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:CORMACK
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WEST LOCUST DRIVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-256-0609
Mailing Address - Fax:
Practice Address - Street 1:136 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:GLEN MORGAN
Practice Address - State:WV
Practice Address - Zip Code:25813-7600
Practice Address - Country:US
Practice Address - Phone:304-256-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV695225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist