Healthcare Provider Details

I. General information

NPI: 1649427311
Provider Name (Legal Business Name): SUSAN CAROLE CORBETT RN, CASAC, CACN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 08/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17-19 SUSSEX STREET
PORT JERVIS NY
12771
US

IV. Provider business mailing address

17-19 SUSSEX STREET
PORT JERVIS NY
12771
US

V. Phone/Fax

Practice location:
  • Phone: 845-856-6344
  • Fax: 845-856-4091
Mailing address:
  • Phone: 845-856-6344
  • Fax: 845-856-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number327966-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: