Provider Demographics
NPI:1912413774
Name:MCCORMICK, MIESHA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:MIESHA
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-4907
Mailing Address - Country:US
Mailing Address - Phone:631-522-0548
Mailing Address - Fax:
Practice Address - Street 1:876 SUNRISE HWY STE 16
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5908
Practice Address - Country:US
Practice Address - Phone:631-522-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management