Provider Demographics
NPI:1407255367
Name:CORLISS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CORLISS
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 1:1680 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1001
Mailing Address - Country:US
Mailing Address - Phone:860-236-4511
Mailing Address - Fax:
Practice Address - Street 1:1680 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1001
Practice Address - Country:US
Practice Address - Phone:860-236-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2014-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker