Healthcare Provider Details

I. General information

NPI: 1053433771
Provider Name (Legal Business Name): FAITH MCCORMACK P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9754 PINE POINT DR
LAKELAND TN
38002-8402
US

IV. Provider business mailing address

9754 PINE POINT DR
LAKELAND TN
38002-8402
US

V. Phone/Fax

Practice location:
  • Phone: 901-382-5052
  • Fax: 901-382-5052
Mailing address:
  • Phone: 901-382-5052
  • Fax: 901-382-5052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0000006956
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3688
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005527
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: