Provider Demographics
NPI:1053139758
Name:MCCORMACK, LISA FREW (INTERN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:FREW
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 W 4650 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-8956
Mailing Address - Country:US
Mailing Address - Phone:385-444-5004
Mailing Address - Fax:
Practice Address - Street 1:5300 S 500 E STE 6
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6955
Practice Address - Country:US
Practice Address - Phone:801-392-0942
Practice Address - Fax:801-392-0943
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist