Healthcare Provider Details

I. General information

NPI: 1184378838
Provider Name (Legal Business Name): ROGER D. CORLEY JR. P-LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 AVIGNON DR STE C
RIDGELAND MS
39157-5186
US

IV. Provider business mailing address

517 HAZELTON DR
MADISON MS
39110-7476
US

V. Phone/Fax

Practice location:
  • Phone: 601-850-7047
  • Fax:
Mailing address:
  • Phone: 731-402-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP-0774
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: