Provider Demographics
NPI:1073186680
Name:HART, CORRIN NICOLE (PLPC)
Entity Type:Individual
Prefix:
First Name:CORRIN
Middle Name:NICOLE
Last Name:HART
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:FOUR SEASONS
Mailing Address - State:MO
Mailing Address - Zip Code:65049-5001
Mailing Address - Country:US
Mailing Address - Phone:573-552-1555
Mailing Address - Fax:
Practice Address - Street 1:312 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:FOUR SEASONS
Practice Address - State:MO
Practice Address - Zip Code:65049-5001
Practice Address - Country:US
Practice Address - Phone:573-552-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health