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General NPI Number Information
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NPI Number | 1336796747
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Entity Type | Individual
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Provider Name | KELLIE MCCORMACK PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 08/20/2019
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Last Update Date | 08/20/2019
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Provider Practice Location Address
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Address Line | 11719 CHAPMAN HWY STE 104
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City | SEYMOUR
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State | TN
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Zip | 37865-5264
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Country | US
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Telephone | 865-773-0479
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Fax |
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Provider Business Mailing Address
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Address Line | 1444 KAY VIEW DR
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City | SEVIERVILLE
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State | TN
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Zip | 37876-0268
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Country | US
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Telephone | 865-254-7194
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 12505
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License Number State | TN
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