Provider Demographics
NPI:1740502913
Name:MCCORMACK, JULIE ANNE (MPT)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANNE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:ANNE
Other - Last Name:ROSKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1987 E 500 S
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-9602
Mailing Address - Country:US
Mailing Address - Phone:765-779-4394
Mailing Address - Fax:765-779-4394
Practice Address - Street 1:1118 W CROSS ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-9530
Practice Address - Country:US
Practice Address - Phone:765-643-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004144A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist