Healthcare Provider Details

I. General information

NPI: 1124559232
Provider Name (Legal Business Name): CORVELL COBURN LCSW, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 KING RD
HATTIESBURG MS
39402-8503
US

IV. Provider business mailing address

262 KING RD
HATTIESBURG MS
39402-8503
US

V. Phone/Fax

Practice location:
  • Phone: 662-769-1024
  • Fax:
Mailing address:
  • Phone: 662-769-1024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC11412
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number906622
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: