Provider Demographics
NPI:1255136255
Name:MCCORMACK BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:MCCORMACK BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MPS, LPCC, LADC
Authorized Official - Phone:612-280-9541
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-0043
Mailing Address - Country:US
Mailing Address - Phone:612-280-9541
Mailing Address - Fax:
Practice Address - Street 1:12775 SWALLOW ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-2587
Practice Address - Country:US
Practice Address - Phone:612-280-9541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty