Provider Demographics
NPI:1700309473
Name:MCCORMICK, THERESA (LMFT, LEP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LMFT, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 FOULGER DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7910
Mailing Address - Country:US
Mailing Address - Phone:925-408-8867
Mailing Address - Fax:
Practice Address - Street 1:350 COLLEGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5125
Practice Address - Country:US
Practice Address - Phone:925-408-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4267103T00000X
CA147339106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700309473Medicaid