Provider Demographics
NPI:1770226573
Name:CORBIN, GRADY RICHARD (LPC)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:RICHARD
Last Name:CORBIN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 GULF AVE APT 29
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-3436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2224 25TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-4520
Practice Address - Country:US
Practice Address - Phone:479-244-0495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS222101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty