=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063921740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES CORBALLY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 CHURCH ST STE 3G
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-281-3330
-----------------------------------------------------
Fax | 802-540-8199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 CHURCH ST STE 3G
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-281-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | MR. CHARLES J. CORBALLY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 802-281-3330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 089.0117025
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------