Provider Demographics
NPI:1548496151
Name:MCCORMACK, TOMMIE ANN (DPT)
Entity type:Individual
Prefix:DR
First Name:TOMMIE
Middle Name:ANN
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:TOMMIE
Other - Middle Name:ANN
Other - Last Name:FRIDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 ZORN AVE
Mailing Address - Street 2:#39
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-3501
Mailing Address - Country:US
Mailing Address - Phone:502-599-0702
Mailing Address - Fax:
Practice Address - Street 1:3901 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4312
Practice Address - Country:US
Practice Address - Phone:904-858-7301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist