Provider Demographics
NPI:1710181441
Name:MCCORMICK, LAURA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 AZALEA PL
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-7218
Mailing Address - Country:US
Mailing Address - Phone:415-450-5067
Mailing Address - Fax:415-499-8620
Practice Address - Street 1:7 MOUNT LASSEN DR
Practice Address - Street 2:SUITE C-257
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1148
Practice Address - Country:US
Practice Address - Phone:415-450-5067
Practice Address - Fax:415-499-8620
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17441103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical