Provider Demographics
NPI:1447331582
Name:CORMACK, PETER H (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:H
Last Name:CORMACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 LAKEVILLE ROAD
Mailing Address - Street 2:P. O. BOX 356
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454
Mailing Address - Country:US
Mailing Address - Phone:585-243-2394
Mailing Address - Fax:
Practice Address - Street 1:PETER H. CORMACK 4828 LAKEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454
Practice Address - Country:US
Practice Address - Phone:585-243-2394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003370-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical