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General NPI Number Information
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NPI Number | 1164686804
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Entity Type | Individual
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Provider Name | MICHAEL P MCCORMICK CASAC
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Gender | Male
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Dates
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Enumeration Date | 07/11/2008
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Last Update Date | 01/30/2017
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Provider Practice Location Address
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Address Line | 2435 6TH AVE
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City | TROY
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State | NY
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Zip | 12180-2227
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Country | US
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Telephone | 518-274-5143
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Fax | 518-273-1350
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Provider Business Mailing Address
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Address Line | 79 GLENRIDGE RD
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City | GLENVILLE
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State | NY
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Zip | 12302-4523
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Country | US
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Telephone | 518-952-8408
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Fax | 518-952-8287
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 19686
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License Number State | NY
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