Provider Demographics
NPI:1548878713
Name:MCCORMICK, CASE JOSEPH (PTA)
Entity type:Individual
Prefix:
First Name:CASE
Middle Name:JOSEPH
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S 12TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENT
Mailing Address - State:MN
Mailing Address - Zip Code:55947-1449
Mailing Address - Country:US
Mailing Address - Phone:507-458-1971
Mailing Address - Fax:
Practice Address - Street 1:3501 PARK LANE DR
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7747
Practice Address - Country:US
Practice Address - Phone:608-789-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3052-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant