Healthcare Provider Details

I. General information

NPI: 1982929550
Provider Name (Legal Business Name): KATHRYN LEE CORLEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 OLD OLIVE ST. RD. SUITE 202
ST. LOUIS MO
63141
US

IV. Provider business mailing address

10420 OLD OLIVE ST. RD. SUITE 202
ST. LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-9700
  • Fax: 314-991-7779
Mailing address:
  • Phone: 314-991-9700
  • Fax: 314-991-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002714
License Number StateMO

VIII. Authorized Official

Name: KATHRYN LEE CORLEY
Title or Position: LLC
Credential:
Phone: 314-991-9700