Provider Demographics
NPI:1225798499
Name:CORBIN, DOLORES VALLI
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:VALLI
Last Name:CORBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOLORES
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1691 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-6959
Mailing Address - Country:US
Mailing Address - Phone:850-272-6789
Mailing Address - Fax:
Practice Address - Street 1:1691 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-6959
Practice Address - Country:US
Practice Address - Phone:850-272-6879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-144655106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician