MEDICARE: DR. BRUCE K MCCORMICK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	631	LA
2	103TC1900X	Counseling Psychologist	631	LA
3	103TC2200X	Clinical Child & Adolescent Psychologist	631	LA
4	103TF0000X	Family Psychologist	631	LA
5	103TP0016X	Prescribing (Medical) Psychologist	631MP	LA
6	103TS0200X	School Psychologist	631	LA
7	106H00000X	Marriage & Family Therapist	631	LA
8	103TP0016X	Prescribing (Medical) Psychologist	MPAP.000013	LA

General Provider Information

NPI Number	:	1043327968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE K MCCORMICK PHD

Provider Business Mailing Address
First Line	:	3341 YOUREE DR STE 20A
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2149
Country	:	US
Telephone Number	:	318-865-7500
Fax Number	:	318-868-2035

Provider Business Practice Location Address
First Line	:	3341 YOUREE DR STE 20A
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2149
Country	:	US
Telephone Number	:	318-865-7500
Fax Number	:	318-868-2035

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	09/19/2023

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