Provider Demographics
NPI:1154807139
Name:MCCORMICK, COLLEEN ANN
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:MCCORMICK
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 1:1315 ROLLING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5449
Mailing Address - Country:US
Mailing Address - Phone:916-677-6840
Mailing Address - Fax:
Practice Address - Street 1:8801 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3257
Practice Address - Country:US
Practice Address - Phone:916-382-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00004855103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst