Healthcare Provider Details

I. General information

NPI: 1679200471
Provider Name (Legal Business Name): COREY BOREN PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N HILLCREST DR
GRANBY MO
64844-8198
US

IV. Provider business mailing address

222 N HILLCREST DR
GRANBY MO
64844-8198
US

V. Phone/Fax

Practice location:
  • Phone: 916-893-4528
  • Fax:
Mailing address:
  • Phone: 916-893-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number458632154989544
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4521033015
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8469754655565
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11564758-4805
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: