Provider Demographics
NPI:1750463493
Name:MCCORMACK, MARLY J (LMSW)
Entity Type:Individual
Prefix:
First Name:MARLY
Middle Name:J
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12231 ASHLEY DR # A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2775
Mailing Address - Country:US
Mailing Address - Phone:228-832-2400
Mailing Address - Fax:228-832-2431
Practice Address - Street 1:12231 ASHLEY DR # A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2775
Practice Address - Country:US
Practice Address - Phone:228-832-2400
Practice Address - Fax:228-832-2431
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM46781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical