Provider Demographics
NPI:1649573924
Name:CORLEY, AQUILA ROSE
Entity Type:Individual
Prefix:
First Name:AQUILA
Middle Name:ROSE
Last Name:CORLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15408
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-5408
Mailing Address - Country:US
Mailing Address - Phone:805-541-5144
Mailing Address - Fax:
Practice Address - Street 1:277 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5039
Practice Address - Country:US
Practice Address - Phone:805-541-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health