Provider Demographics
NPI:1720859390
Name:MCCORMICK, LISA ELLEN (LCMHCA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELLEN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ELLEN
Other - Last Name:ALLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2525 DOWN STREAM LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-2101
Mailing Address - Country:US
Mailing Address - Phone:785-259-0878
Mailing Address - Fax:
Practice Address - Street 1:3825 MARKET ST STE 4
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1426
Practice Address - Country:US
Practice Address - Phone:910-777-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
NCA19553101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional