Provider Demographics
NPI:1790498822
Name:MCCORMICK-LYNCH, PRINCESS LA FAYE
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:LA FAYE
Last Name:MCCORMICK-LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 VETERANS MEMORIAL BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-4003
Mailing Address - Country:US
Mailing Address - Phone:504-399-1161
Mailing Address - Fax:
Practice Address - Street 1:1919 VETERANS MEMORIAL BLVD STE 302
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-4003
Practice Address - Country:US
Practice Address - Phone:504-399-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 171M00000X
LA17472104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker