MEDICARE: BRENDA MARIE CORKUM MA LMHC

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	LH00008132	WA

General Provider Information

NPI Number	:	1720242969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA MARIE CORKUM MA LMHC

Provider Business Mailing Address
First Line	:	1822 BLACK LAKE BLVD SW
Second Line	:	SUITE 102-D
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5628
Country	:	US
Telephone Number	:	360-866-2919
Fax Number	:	360-943-5382

Provider Business Practice Location Address
First Line	:	1822 BLACK LAKE BLVD SW
Second Line	:	SUITE 102-D
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5628
Country	:	US
Telephone Number	:	360-866-2919
Fax Number	:	360-943-5382

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

Provider Enumeration Date	:	07/16/2008
Last Update Date	:	07/16/2008

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