Provider Demographics
NPI:1275563124
Name:CORGIAT, MICHELE DIANA (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:DIANA
Last Name:CORGIAT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MISS
Other - First Name:MICHELE
Other - Middle Name:DIANA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 579743
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-9743
Mailing Address - Country:US
Mailing Address - Phone:209-402-2717
Mailing Address - Fax:209-529-0404
Practice Address - Street 1:2125 WYLIE DR
Practice Address - Street 2:SUITE 9
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3800
Practice Address - Country:US
Practice Address - Phone:209-402-2717
Practice Address - Fax:209-529-0404
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT40776106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist