Provider Demographics
NPI:1558699496
Name:MCCORMICK, BRYAN P (PHD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:P
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E 7TH ST
Mailing Address - Street 2:HPER BLDG, RM. 133
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-7109
Mailing Address - Country:US
Mailing Address - Phone:812-855-4711
Mailing Address - Fax:812-855-3998
Practice Address - Street 1:1025 E 7TH ST
Practice Address - Street 2:HPER BLDG, RM. 133
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7109
Practice Address - Country:US
Practice Address - Phone:812-855-4711
Practice Address - Fax:812-855-3998
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist