Provider Demographics
NPI:1720540651
Name:DORSEY, COREY W
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:W
Last Name:DORSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 RICHMOND HOUSE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-1054
Mailing Address - Country:US
Mailing Address - Phone:814-807-0422
Mailing Address - Fax:
Practice Address - Street 1:1611 PEACH ST STE 185
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-2125
Practice Address - Country:US
Practice Address - Phone:814-480-8985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABHQ02610101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABHQ02610OtherPENNSYLVANIA BUREAU OF PROFESSIONAL & OCCUPATIONAL AFFAIRS