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
State | License ID | Taxonomies |
---|---|---|
IL | 071004121 | 103TC0700X |
IL | 166000395 | 106H00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
974570 | Medicare PIN |