Provider Demographics
NPI:1912757295
Name:MCCORT, GAVIN WARREN LINDSEY
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:WARREN LINDSEY
Last Name:MCCORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 S EGRET BAY BLVD APT 1707
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5498
Mailing Address - Country:US
Mailing Address - Phone:256-529-5305
Mailing Address - Fax:
Practice Address - Street 1:1805 S EGRET BAY BLVD APT 1707
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-5498
Practice Address - Country:US
Practice Address - Phone:256-529-5305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87589133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered