Provider Demographics
NPI:1033817036
Name:MATLOCK-CORLEY, EVALENA (MSW RSW)
Entity Type:Individual
Prefix:
First Name:EVALENA
Middle Name:
Last Name:MATLOCK-CORLEY
Suffix:
Gender:F
Credentials:MSW RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 BURNING BUSH RD.
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:ON
Mailing Address - Zip Code:N2V 2C4
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 WEBER STREET N, #101
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:ONTARIO
Practice Address - Zip Code:N2L 4E7
Practice Address - Country:CA
Practice Address - Phone:519-778-1520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ829108104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker