=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922827062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN MCCORMICK LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2024
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 841 MOUNTAIN AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-3463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-774-2273
-----------------------------------------------------
Fax | 973-774-2275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 LEJAY CT
-----------------------------------------------------
City | WHARTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07885-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-317-6856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 44SL07204100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------