Basic Information
| Provider Information | |||||||||
| NPI: | 1215001680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | GLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCORMICK | ||||||||
| OtherFirstName: | PAUL | ||||||||
| OtherMiddleName: | GLEN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 271 MAIN ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021803591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814385550 | ||||||||
| FaxNumber: | 7814385553 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 MAIN ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021803591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814385550 | ||||||||
| FaxNumber: | 7814385553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/10/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 4192 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1899236 | 05 | MA | MEDICAID |