Healthcare Provider Details

I. General information

NPI: 1073287561
Provider Name (Legal Business Name): TRISHA ANNE MCCORMACK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRISHA ANNE MARIANO DPT

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11275 DELAWARE PKWY STE B
CROWN POINT IN
46307-7812
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 219-663-8766
  • Fax:
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number99106004A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05014337A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: