Provider Demographics
NPI:1730446410
Name:FAMILY PSYCHOLOGY AND COUNSELING
Entity type:Organization
Organization Name:FAMILY PSYCHOLOGY AND COUNSELING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:KQ
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-865-7500
Mailing Address - Street 1:1513 LINE AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4621
Mailing Address - Country:US
Mailing Address - Phone:318-865-7500
Mailing Address - Fax:318-868-2035
Practice Address - Street 1:1513 LINE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4621
Practice Address - Country:US
Practice Address - Phone:318-865-7500
Practice Address - Fax:318-868-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C128Medicare UPIN