Provider Demographics
NPI:1811010929
Name:WILBUR, COREY RIORDAN (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:COREY
Middle Name:RIORDAN
Last Name:WILBUR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2712
Mailing Address - Country:US
Mailing Address - Phone:805-443-3710
Mailing Address - Fax:310-868-5371
Practice Address - Street 1:38 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2712
Practice Address - Country:US
Practice Address - Phone:805-443-3710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28700055106H00000X
NY001121106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA951691011OtherEIN