MEDICARE: ROGER D. CORLEY JR. P-LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	P-0774	MS

General Provider Information

NPI Number	:	1184378838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER D. CORLEY JR. P-LPC

Provider Business Mailing Address
First Line	:	517 HAZELTON DR
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-7476
Country	:	US
Telephone Number	:	731-402-6650
Fax Number	:

Provider Business Practice Location Address
First Line	:	745 AVIGNON DR STE C
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-5186
Country	:	US
Telephone Number	:	601-850-7047
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2022
Last Update Date	:	10/31/2023

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