Healthcare Provider Details

I. General information

NPI: 1245695014
Provider Name (Legal Business Name): THOMAS J. CORMICAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 LEDGEVIEW DR
ROCHESTER NH
03839-5619
US

IV. Provider business mailing address

20 LEDGEVIEW DR
ROCHESTER NH
03839-5619
US

V. Phone/Fax

Practice location:
  • Phone: 603-923-8836
  • Fax:
Mailing address:
  • Phone: 603-923-8836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1745
License Number StateNH

VIII. Authorized Official

Name: MR. THOMAS J. CORMICAN
Title or Position: OWNER/CLINICIAN
Credential: LICSW
Phone: 603-923-8836