Healthcare Provider Details

I. General information

NPI: 1982437810
Provider Name (Legal Business Name): SAMANTHA CORLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 BENVOLIO WAY
ST AUGUSTINE FL
32092-4527
US

IV. Provider business mailing address

23 RYBAR LN
PALM COAST FL
32164-6445
US

V. Phone/Fax

Practice location:
  • Phone: 904-347-5111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: