Provider Demographics
NPI:1225389901
Name:PAVELKA, COREY PATRICK (LCSW)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:PATRICK
Last Name:PAVELKA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 SHERRY LN
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-0979
Mailing Address - Country:US
Mailing Address - Phone:817-676-2422
Mailing Address - Fax:
Practice Address - Street 1:2111 W HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5627
Practice Address - Country:US
Practice Address - Phone:817-573-6002
Practice Address - Fax:817-573-6009
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55382101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148686201Medicaid