Provider Demographics
NPI:1568586634
Name:CORLEY, KATHRYN L (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:CORLEY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10420 OLD OLIVE STREET ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-991-9700
Mailing Address - Fax:314-991-7779
Practice Address - Street 1:10420 OLD OLIVE STREET ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-991-9700
Practice Address - Fax:314-991-7779
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0027141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490345907Medicaid
MO000083467Medicare PIN