Provider Demographics
NPI:1891830477
Name:MCCORMACK, ANITA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 S PRAIRIE ST
Mailing Address - Street 2:APT 5
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-1547
Mailing Address - Country:US
Mailing Address - Phone:573-885-0800
Mailing Address - Fax:573-885-1600
Practice Address - Street 1:713 S PRAIRIE ST
Practice Address - Street 2:APT 5
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1547
Practice Address - Country:US
Practice Address - Phone:573-885-0800
Practice Address - Fax:573-885-1600
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050317531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3202OtherMEDICARE PTAN - ORGANIZATION
MOMA3202001OtherMEDICARE PTAN - INDIVIDUAL
MO1891830477Medicaid