Provider Demographics
NPI:1962568691
Name:MCCORMACK, DONNA (PT)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-8532
Mailing Address - Country:US
Mailing Address - Phone:662-286-2787
Mailing Address - Fax:
Practice Address - Street 1:90 CLARK AVE # A
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-2801
Practice Address - Country:US
Practice Address - Phone:662-840-0535
Practice Address - Fax:662-842-7915
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist