Provider Demographics
NPI:1689846172
Name:MCCORMICK, JULIANA SUSAN (LAC)
Entity Type:Individual
Prefix:
First Name:JULIANA
Middle Name:SUSAN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SELBY AVE
Mailing Address - Street 2:SUITE G2
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4508
Mailing Address - Country:US
Mailing Address - Phone:651-224-6678
Mailing Address - Fax:651-224-6772
Practice Address - Street 1:400 SELBY AVE
Practice Address - Street 2:SUITE G2
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4508
Practice Address - Country:US
Practice Address - Phone:651-224-6678
Practice Address - Fax:651-224-6772
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1404171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist