Healthcare Provider Details

I. General information

NPI: 1164262382
Provider Name (Legal Business Name): LAMISHA SHANT'E CORLEY CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 05/27/2024
Certification Date: 05/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E RIVER ST
ELYRIA OH
44035-5902
US

IV. Provider business mailing address

77 BANK ST APT 2A
WATERBURY CT
06702-2237
US

V. Phone/Fax

Practice location:
  • Phone: 475-313-2860
  • Fax:
Mailing address:
  • Phone: 475-313-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: