Healthcare Provider Details

I. General information

NPI: 1689658874
Provider Name (Legal Business Name): URSULA SUE MCCORMICK CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: URSULA SUE MEYER

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

IV. Provider business mailing address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

V. Phone/Fax

Practice location:
  • Phone: 812-339-1691
  • Fax: 812-337-2438
Mailing address:
  • Phone: 812-339-1691
  • Fax: 812-337-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number70000019A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number70000019A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28114646
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: