Provider Demographics
NPI:1770017196
Name:CORRALES, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:CORRALES
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 1:4719 QUAIL LAKES DR
Mailing Address - Street 2:#G240
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3031 W MARCH LN
Practice Address - Street 2:SUITE 117 S
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6500
Practice Address - Country:US
Practice Address - Phone:209-952-2588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist