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General NPI Number Information
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NPI Number | 1033817036
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Entity Type | Individual
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Provider Name | EVALENA MATLOCK-CORLEY MSW RSW
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Gender | Female
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Dates
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Enumeration Date | 02/20/2023
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Last Update Date | 02/20/2023
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Provider Practice Location Address
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Address Line | 420 WEBER STREET N, #101
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City | WATERLOO
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State | ONTARIO
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Zip | N2L 4E7
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Country | CA
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Telephone | 519-778-1520
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Fax |
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Provider Business Mailing Address
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Address Line | 626 BURNING BUSH RD.
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City | WATERLOO
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State | ON
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Zip | N2V 2C4
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Country | CA
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 829108
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License Number State | ZZ
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