Provider Demographics
NPI:1760545917
Name:MCCORMICK, PAUL WAGLER (MS, LAC, BCD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:WAGLER
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:MS, LAC, BCD
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:N
Other - Last Name:WAGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS BCD
Mailing Address - Street 1:911 WAUKESHA ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-8747
Mailing Address - Country:US
Mailing Address - Phone:406-431-7356
Mailing Address - Fax:406-443-1391
Practice Address - Street 1:111 N. LAST CHANCE GULCH SUITE 2A
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601
Practice Address - Country:US
Practice Address - Phone:406-443-1990
Practice Address - Fax:406-443-1391
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1163-LAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4033-96OtherB. C. DIPLOMATE-AMER.BDA
MT761160OtherBCBS MT.