Healthcare Provider Details

I. General information

NPI: 1811472962
Provider Name (Legal Business Name): RAPHAEL CORLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 E 14075 S STE 110
DRAPER UT
84020-5725
US

IV. Provider business mailing address

4460 S HIGHLAND DR
SALT LAKE CITY UT
84124-3543
US

V. Phone/Fax

Practice location:
  • Phone: 801-899-0732
  • Fax:
Mailing address:
  • Phone: 801-273-6345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10853087-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: