Provider Demographics
NPI:1508290453
Name:CORRAL, ROBERT MICHAEL (M ED, CSAYC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:CORRAL
Suffix:
Gender:M
Credentials:M ED, CSAYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3458
Mailing Address - Country:US
Mailing Address - Phone:260-482-9125
Mailing Address - Fax:260-481-2838
Practice Address - Street 1:809 HIGH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2324
Practice Address - Country:US
Practice Address - Phone:260-724-9669
Practice Address - Fax:260-724-4872
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2018-06-22
Deactivation Date:2014-04-02
Deactivation Code:
Reactivation Date:2018-05-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist