MEDICARE: DR. HOLLY CORMIER PH.D.

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	103TC0700X	Clinical Psychologist	071006997	IL

General Provider Information

NPI Number	:	1144479478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOLLY CORMIER PH.D.

Provider Business Mailing Address
First Line	:	139 PINE SHORE DR
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62902-7503
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	139 PINE SHORE DR
Second Line	:	37
City	:	CARBONDALE
State	:	IL
Zip	:	62902-7503
Country	:	US
Telephone Number	:	618-303-9610
Fax Number	:

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

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	07/30/2014

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