Provider Demographics
NPI:1285192468
Name:CORLEY, MAE ROSE
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:ROSE
Last Name:CORLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6822 MOSELLE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1846
Mailing Address - Country:US
Mailing Address - Phone:669-234-0898
Mailing Address - Fax:
Practice Address - Street 1:841 BLOSSOM HILL RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-2704
Practice Address - Country:US
Practice Address - Phone:408-475-8876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist