MEDICARE: GREGORY CORRELL PHD

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	103TC1900X	Counseling Psychologist	20040294A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326045063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY CORRELL PHD

Provider Business Mailing Address
First Line	:	17330 W CENTER RD
Second Line	:	SUITE 110-282
City	:	OMAHA
State	:	NE
Zip	:	68130-2392
Country	:	US
Telephone Number	:	317-446-9288
Fax Number	:

Provider Business Practice Location Address
First Line	:	9904 RIDGEWAY CT
Second Line	:
City	:	MC CORDSVILLE
State	:	IN
Zip	:	46055-9790
Country	:	US
Telephone Number	:	317-335-3871
Fax Number	:

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	09/30/2009

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Directions to “ GREGORY CORRELL PHD” Practice Location

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