Provider Demographics
NPI:1043364045
Name:MCCORMICK, MAUREEN ELEONORA (PHD)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:ELEONORA
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440315
Mailing Address - Street 2:
Mailing Address - City:WEST SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-0027
Mailing Address - Country:US
Mailing Address - Phone:617-970-3275
Mailing Address - Fax:
Practice Address - Street 1:1330 BEACON ST
Practice Address - Street 2:STE 203
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3202
Practice Address - Country:US
Practice Address - Phone:617-970-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7912103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2153512OtherCIGNA BEHAVIORAL HEALTH
MA7224414OtherAETNA HEALTH CARE
MA409535OtherTUFTS PPO
MAW06095OtherBCBS OF MASSACHUSETTS
MAP49487Medicare UPIN
MAW06095OtherBCBS OF MASSACHUSETTS
MAW51378Medicare ID - Type UnspecifiedSALEM OFFICE