MEDICARE: THERESA MCCORMICK LMFT, LEP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	4267	CA
2	106H00000X	Marriage & Family Therapist	147339	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700309473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MCCORMICK LMFT, LEP

Provider Business Mailing Address
First Line	:	4722 FOULGER DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7910
Country	:	US
Telephone Number	:	925-408-8867
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 COLLEGE AVE STE 101
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-5125
Country	:	US
Telephone Number	:	925-408-8867
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	03/07/2025

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