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General NPI Number Information
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NPI Number | 1073201935
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Entity Type | Individual
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Provider Name | CORY MICHAEL CARLINE EDD, MSW, LCSW
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Gender | Male
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Dates
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Enumeration Date | 04/28/2023
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Last Update Date | 10/22/2025
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Provider Practice Location Address
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Address Line | 2640 W POINT RD
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City | GREEN BAY
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State | WI
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Zip | 54304-1344
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Country | US
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Telephone | 920-490-3790
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Fax |
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Provider Business Mailing Address
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Address Line | 2676 TROJAN DR APT G16
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City | GREEN BAY
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State | WI
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Zip | 54304-1260
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Country | US
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 35505
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 12468-123
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 131470-121
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License Number State | WI
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