Provider Demographics
NPI:1225584980
Name:CORBALLY, CHARLES JOSEPH (LICSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:CORBALLY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHURCH STREET
Mailing Address - Street 2:SUITE 3G
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-281-3330
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST
Practice Address - Street 2:SUITE 3G
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4299
Practice Address - Country:US
Practice Address - Phone:802-281-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01170251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1028428Medicaid