Provider Demographics
NPI:1760690689
Name:TAYLOR-DUNN, CORLISS LESLIE (MA, LMFT)
Entity Type:Individual
Prefix:MS
First Name:CORLISS
Middle Name:LESLIE
Last Name:TAYLOR-DUNN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 MACDONALD PL
Mailing Address - Street 2:HCR 68 BOX 80
Mailing Address - City:FORT GARLAND
Mailing Address - State:CO
Mailing Address - Zip Code:81133-9758
Mailing Address - Country:US
Mailing Address - Phone:719-379-3788
Mailing Address - Fax:719-379-3788
Practice Address - Street 1:930 STATE AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-3142
Practice Address - Country:US
Practice Address - Phone:719-379-3788
Practice Address - Fax:719-379-3788
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 37343106H00000X
CO72160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist