Healthcare Provider Details

I. General information

NPI: 1376455436
Provider Name (Legal Business Name): ISABELLA GRACE MCCORMACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 UNIVERSITY ST
VALLEY STREAM NY
11581-3517
US

IV. Provider business mailing address

2 GLENWOOD RD
SCARSDALE NY
10583-2718
US

V. Phone/Fax

Practice location:
  • Phone: 516-578-4567
  • Fax: 516-261-5363
Mailing address:
  • Phone: 516-578-4567
  • Fax: 516-261-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP145880
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: