Healthcare Provider Details

I. General information

NPI: 1841933058
Provider Name (Legal Business Name): COREY KNEEDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BELAIRE AVE STE 350
CHESAPEAKE VA
23320-4789
US

IV. Provider business mailing address

325 S ASH ST
NOWATA OK
74048-4628
US

V. Phone/Fax

Practice location:
  • Phone: 804-207-6737
  • Fax:
Mailing address:
  • Phone: 620-515-5897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0704017011
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: