Provider Demographics
NPI:1629178413
Name:CORLEY, RITA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:
Last Name:CORLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:RITA
Other - Middle Name:
Other - Last Name:CORLEY-BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:360 W WELLINGTON AVE
Mailing Address - Street 2:18A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5651
Mailing Address - Country:US
Mailing Address - Phone:773-549-0641
Mailing Address - Fax:773-549-7311
Practice Address - Street 1:1580 N NORTHWEST HWY
Practice Address - Street 2:121-D
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1444
Practice Address - Country:US
Practice Address - Phone:847-297-5848
Practice Address - Fax:773-549-7311
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004121103TC0700X
IL166000395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
974570Medicare PIN