Provider Demographics
NPI:1558442103
Name:CORMICK, CAROL WINIFRED (MS)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:WINIFRED
Last Name:CORMICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10402 N WOODMERE RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-3464
Mailing Address - Country:US
Mailing Address - Phone:813-988-4886
Mailing Address - Fax:813-988-6438
Practice Address - Street 1:1532 US 41 NORTH
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33539
Practice Address - Country:US
Practice Address - Phone:813-948-6000
Practice Address - Fax:813-988-6438
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1742106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist