Provider Demographics
NPI:1649879800
Name:MCCORMACK, CHRISTINE (LMT, CPT)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:NJ
Mailing Address - Zip Code:07461-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 4TH ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:NJ
Practice Address - Zip Code:07461-2512
Practice Address - Country:US
Practice Address - Phone:908-391-4954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00984600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist