Provider Demographics
NPI:1497795538
Name:CORELLI, TODD B (PHD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:B
Last Name:CORELLI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-7748
Mailing Address - Country:US
Mailing Address - Phone:801-643-1379
Mailing Address - Fax:801-547-1929
Practice Address - Street 1:1452 EVERGREEN LN
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-7748
Practice Address - Country:US
Practice Address - Phone:801-643-1379
Practice Address - Fax:801-547-1929
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT376650-2501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health