Basic Information
| Provider Information | |||||||||
| NPI: | 1710193727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 8TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | MANDAN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585544029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016635454 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | MENTAL HEALTH | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012393700 | ||||||||
| FaxNumber: | 7012372642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1449 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.