Provider Demographics
NPI:1043327968
Name:MCCORMICK, BRUCE K (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:K
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:B
Other - Middle Name:K
Other - Last Name:MCCORMICK PHD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3341 YOUREE DR STE 20A
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2149
Mailing Address - Country:US
Mailing Address - Phone:318-865-7500
Mailing Address - Fax:318-868-2035
Practice Address - Street 1:3341 YOUREE DR STE 20A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-865-7500
Practice Address - Fax:318-868-2035
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA631103T00000X, 103TC1900X, 103TC2200X, 103TF0000X, 103TS0200X, 106H00000X
LA631MP103TP0016X
LAMPAP.000013103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C128Medicare ID - Type Unspecified