=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275563124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE DIANA CORGIAT MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2125 WYLIE DR SUITE 9
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-402-2717
-----------------------------------------------------
Fax | 209-529-0404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 579743
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95357-9743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-402-2717
-----------------------------------------------------
Fax | 209-529-0404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT40776
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------