Provider Demographics
NPI:1083345276
Name:TATE, COREY MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:MICHAEL
Last Name:TATE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 N 35TH AVE APT 1042
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-3867
Mailing Address - Country:US
Mailing Address - Phone:623-418-4657
Mailing Address - Fax:
Practice Address - Street 1:4326 N 35TH AVE APT 1042
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3867
Practice Address - Country:US
Practice Address - Phone:623-418-4657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172M00000X
AZ28168225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty