Healthcare Provider Details

I. General information

NPI: 1043327968
Provider Name (Legal Business Name): BRUCE K MCCORMICK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: B K MCCORMICK PHD

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 YOUREE DR STE 20A
SHREVEPORT LA
71105-2149
US

IV. Provider business mailing address

3341 YOUREE DR STE 20A
SHREVEPORT LA
71105-2149
US

V. Phone/Fax

Practice location:
  • Phone: 318-865-7500
  • Fax: 318-868-2035
Mailing address:
  • Phone: 318-865-7500
  • Fax: 318-868-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number631
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number631
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number631
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number631
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number631MP
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number631
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number631
License Number StateLA
# 8
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMPAP.000013
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: