Provider Demographics
NPI:1134263304
Name:MCCORMACK, THOMAS (LICSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7108
Mailing Address - Country:US
Mailing Address - Phone:603-433-2626
Mailing Address - Fax:603-433-2736
Practice Address - Street 1:1 CATE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7108
Practice Address - Country:US
Practice Address - Phone:603-433-2626
Practice Address - Fax:603-433-2736
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH161104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHQX2615Medicare PIN
NHRE3194Medicare PIN