Provider Demographics
NPI:1184086829
Name:MCCORMICK, GENA (PTA)
Entity type:Individual
Prefix:MRS
First Name:GENA
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-1533
Mailing Address - Country:US
Mailing Address - Phone:925-336-1386
Mailing Address - Fax:
Practice Address - Street 1:1757 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-1533
Practice Address - Country:US
Practice Address - Phone:925-336-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT10777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant