Provider Demographics
NPI:1992337976
Name:MCCORMACK ENTERPRISE, LLC
Entity type:Organization
Organization Name:MCCORMACK ENTERPRISE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:318-237-8216
Mailing Address - Street 1:1003 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2135
Mailing Address - Country:US
Mailing Address - Phone:318-237-8216
Mailing Address - Fax:
Practice Address - Street 1:1003 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2135
Practice Address - Country:US
Practice Address - Phone:318-237-8216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2442210Medicaid