Healthcare Provider Details

I. General information

NPI: 1891830477
Provider Name (Legal Business Name): ANITA MCCORMACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 S PRAIRIE ST APT 5
CUBA MO
65453-1547
US

IV. Provider business mailing address

713 S PRAIRIE ST APT 5
CUBA MO
65453-1547
US

V. Phone/Fax

Practice location:
  • Phone: 573-885-0800
  • Fax: 573-885-1600
Mailing address:
  • Phone: 573-885-0800
  • Fax: 573-885-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005031753
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: