Provider Demographics
NPI:1104959428
Name:MCCORMICK, TARA LINETTE (OTD, OTRL)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LINETTE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:OTD, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4990 KISER ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:NC
Mailing Address - Zip Code:28682-9773
Mailing Address - Country:US
Mailing Address - Phone:508-243-2433
Mailing Address - Fax:
Practice Address - Street 1:1178B RIVER HWY STE 100
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9064
Practice Address - Country:US
Practice Address - Phone:508-243-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5915225XP0200X
NC2096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOT0174OtherBLUECROSS BLUE SHIELD