Provider Demographics
NPI:1356863187
Name:CORRELL, JUDITH ANN (MT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:CORRELL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7080 SPRINGWOOD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-8208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 BEECH ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1427
Practice Address - Country:US
Practice Address - Phone:989-386-2384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist