Healthcare Provider Details

I. General information

NPI: 1033817036
Provider Name (Legal Business Name): EVALENA MATLOCK-CORLEY MSW RSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 WEBER STREET N, #101
WATERLOO ONTARIO
N2L 4E7
CA

IV. Provider business mailing address

626 BURNING BUSH RD.
WATERLOO ON
N2V 2C4
CA

V. Phone/Fax

Practice location:
  • Phone: 519-778-1520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number829108
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: