Provider Demographics
NPI:1518292515
Name:CORBY, KATHLEEN WAGNER (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:WAGNER
Last Name:CORBY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 CLUB RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-3673
Mailing Address - Country:US
Mailing Address - Phone:704-906-9574
Mailing Address - Fax:
Practice Address - Street 1:2303 CLUB RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-3673
Practice Address - Country:US
Practice Address - Phone:704-906-9574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6987OtherOCCUPATIONAL THERAPY LICENSE #