Provider Demographics
NPI:1659646545
Name:PATHANOS, CORBY W (LPC)
Entity Type:Individual
Prefix:
First Name:CORBY
Middle Name:W
Last Name:PATHANOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 RICE RD APT 403
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1089
Mailing Address - Country:US
Mailing Address - Phone:850-512-6788
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 216
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:601-859-8371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1394101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional