Healthcare Provider Details

I. General information

NPI: 1700566254
Provider Name (Legal Business Name): JOSEPH EARL CORLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 MIDSTREAM CT
MESQUITE TX
75181-4295
US

IV. Provider business mailing address

3310 MIDSTREAM CT
MESQUITE TX
75181-4295
US

V. Phone/Fax

Practice location:
  • Phone: 612-408-6187
  • Fax:
Mailing address:
  • Phone: 612-408-6187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3232
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number92146
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0023364
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: