Provider Demographics
NPI:1790367498
Name:MCCORMICK, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 W STETSON AVE # 206
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-9740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1370 S STATE ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4922
Practice Address - Country:US
Practice Address - Phone:951-791-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
171M00000X
CA141972106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator