Healthcare Provider Details

I. General information

NPI: 1235491333
Provider Name (Legal Business Name): CATHERINE MONICA MCCORMICK-DEATON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 SMITH AVE N
SAINT PAUL MN
55102-2424
US

IV. Provider business mailing address

280 SMITH AVE N
SAINT PAUL MN
55102-2424
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-5959
  • Fax:
Mailing address:
  • Phone: 651-241-5959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number62858
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: