=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225236441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLETTE LEE CORCORAN M.ED., LMHC, ESQUIRE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2007
-----------------------------------------------------
Last Update Date | 08/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 885 SE 47TH TER SUITE D
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33904-9079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-549-5363
-----------------------------------------------------
Fax | 239-549-5325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 885 SE 47TH TER SUITE D
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33904-9079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-549-5363
-----------------------------------------------------
Fax | 239-549-5325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6446
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------