Provider Demographics
NPI:1568755619
Name:MCCORMACK, MELISSA (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 BROOKLINE AVE
Mailing Address - Street 2:APT. 533
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 EAST ST
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1950
Practice Address - Country:US
Practice Address - Phone:978-851-7321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000003041133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered