Provider Demographics
NPI:1679614473
Name:CORPOLONGO, MICHAEL JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:CORPOLONGO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 AUTO CENTER WAY
Mailing Address - Street 2:STE 203
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-4388
Mailing Address - Country:US
Mailing Address - Phone:360-377-8171
Mailing Address - Fax:
Practice Address - Street 1:4841 AUTO CENTER WAY
Practice Address - Street 2:STE 203
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-4388
Practice Address - Country:US
Practice Address - Phone:360-377-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000842103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical