Provider Demographics
NPI:1770769218
Name:MCCORD, MAURY BRUTON (LAC)
Entity type:Individual
Prefix:
First Name:MAURY
Middle Name:BRUTON
Last Name:MCCORD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5723
Mailing Address - Country:US
Mailing Address - Phone:870-367-2461
Mailing Address - Fax:870-460-6133
Practice Address - Street 1:1127 SECOND ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1541
Practice Address - Country:US
Practice Address - Phone:870-265-3808
Practice Address - Fax:870-265-2733
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0901003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0018205Medicaid