Healthcare Provider Details

I. General information

NPI: 1134263304
Provider Name (Legal Business Name): THOMAS MCCORMACK LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CATE ST
PORTSMOUTH NH
03801-7108
US

IV. Provider business mailing address

1 CATE ST
PORTSMOUTH NH
03801-7108
US

V. Phone/Fax

Practice location:
  • Phone: 603-433-2626
  • Fax: 603-433-2736
Mailing address:
  • Phone: 603-433-2626
  • Fax: 603-433-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberNH161
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: