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General NPI Number Information
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NPI Number | 1104134022
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Entity Type | Organization
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Legal Business Name | DEBRA CORN AGENCY
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Dates
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Enumeration Date | 09/14/2010
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Last Update Date | 09/14/2010
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Provider Practice Location Address
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Address Line | 200 PROFESSIONAL CT STE A
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City | LAFAYETTE
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State | IN
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Zip | 47905-5134
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Country | US
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Telephone | 765-479-2409
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Fax |
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Provider Business Mailing Address
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Address Line | 200 PROFESSIONAL CT STE A
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City | LAFAYETTE
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State | IN
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Zip | 47905-5134
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Country | US
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Telephone | 765-479-2409
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Fax |
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Authorized Official
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Title or Position | MARRIAGE & FAMILY THERAPIST
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Name | AJA MUTZL
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Credential | M.A.
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Telephone | 765-449-1992
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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