Provider Demographics
NPI:1124632385
Name:MCCORMACK, KATHRYN ANNE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1230
Mailing Address - Country:US
Mailing Address - Phone:781-479-6314
Mailing Address - Fax:
Practice Address - Street 1:459 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4125
Practice Address - Country:US
Practice Address - Phone:781-479-6314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health