Healthcare Provider Details

I. General information

NPI: 1295054633
Provider Name (Legal Business Name): ROBERT MILLSAPS CORBAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4577 S EASON BLVD SUITE E-F
TUPELO MS
38801-6590
US

IV. Provider business mailing address

4577 S EASON BLVD SUITE E-F
TUPELO MS
38801-6590
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-7590
  • Fax: 662-377-7595
Mailing address:
  • Phone: 662-377-7590
  • Fax: 662-377-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC0273
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: