Provider Demographics
NPI:1508590696
Name:CORCORAN, CHRISTIAN (CMP)
Entity Type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 7TH ST APT 10
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:834 7TH ST APT 10
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-1492
Practice Address - Country:US
Practice Address - Phone:917-587-2416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58382225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty