Provider Demographics
NPI:1083168090
Name:STOVALL, CORINNE
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:STOVALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 NE 134TH ST STE 220A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2722
Mailing Address - Country:US
Mailing Address - Phone:253-508-4602
Mailing Address - Fax:360-737-6663
Practice Address - Street 1:1313 NE 134TH ST STE 220A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2722
Practice Address - Country:US
Practice Address - Phone:253-508-4602
Practice Address - Fax:360-737-6663
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WACG60865801101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)