Healthcare Provider Details

I. General information

NPI: 1336780360
Provider Name (Legal Business Name): SHERRYL LYNN MCCORKLE CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 E BABBITT ST
DAYTON OH
45405-4903
US

IV. Provider business mailing address

4404 WOLF RD
DAYTON OH
45416-2228
US

V. Phone/Fax

Practice location:
  • Phone: 937-253-1680
  • Fax:
Mailing address:
  • Phone: 937-718-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number130203
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: