Provider Demographics
NPI:1609051804
Name:MCCORMACK, GUY LOUIS (PHD OTRL)
Entity Type:Individual
Prefix:MR
First Name:GUY
Middle Name:LOUIS
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:PHD OTRL
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:UNIVERSITY OF MISSOURI
Mailing Address - Street 2:406 LEWIS
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-0001
Mailing Address - Country:US
Mailing Address - Phone:573-882-4183
Mailing Address - Fax:573-884-2610
Practice Address - Street 1:300 PORTLAND ST
Practice Address - Street 2:SUITE 110 THOMPSON CENTER
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211
Practice Address - Country:US
Practice Address - Phone:573-882-6081
Practice Address - Fax:573-884-2610
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2003030520225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA223834OtherAOTA CERTIFICATION