Basic Information
Provider Information | |||||||||
NPI: | 1528475191 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCORMICK | ||||||||
FirstName: | DIANE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCMHC, MLADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GREGORY | ||||||||
OtherFirstName: | DIANE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MLADC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7 PROSPECT ST | ||||||||
Address2: |   | ||||||||
City: | NASHUA | ||||||||
State: | NH | ||||||||
PostalCode: | 03060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6038896147 | ||||||||
FaxNumber: | 6038831568 | ||||||||
Practice Location | |||||||||
Address1: | 440 AMHERST ST | ||||||||
Address2: |   | ||||||||
City: | NASHUA | ||||||||
State: | NH | ||||||||
PostalCode: | 03063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6038896147 | ||||||||
FaxNumber: | 6038831568 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2014 | ||||||||
LastUpdateDate: | 02/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0584 | NH | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 1073 | NH | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.