Provider Demographics
NPI:1295071611
Name:MCCORMICK, SHANE KENNETH (OTR/L)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:KENNETH
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 SAINT JOSEPHS BLVD
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3223
Mailing Address - Country:US
Mailing Address - Phone:607-733-6541
Mailing Address - Fax:
Practice Address - Street 1:310 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8636
Practice Address - Country:US
Practice Address - Phone:307-734-2877
Practice Address - Fax:307-734-2827
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1386225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist