Healthcare Provider Details

I. General information

NPI: 1285030676
Provider Name (Legal Business Name): TRACI MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 BANNING RD
CINCINNATI OH
45239-5207
US

IV. Provider business mailing address

3240 BANNING RD
CINCINNATI OH
45239-5207
US

V. Phone/Fax

Practice location:
  • Phone: 513-825-7070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3107992
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: