Healthcare Provider Details

I. General information

NPI: 1871618223
Provider Name (Legal Business Name): ADELAIDE CORVELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 4TH AVE
BAY SHORE NY
11706-7908
US

IV. Provider business mailing address

78 LAKEVIEW DR
KINGS PARK NY
11754-2316
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-6707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberR014050
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: