Provider Demographics
NPI:1821660267
Name:CORKELL, KAITLYN ROSE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:CORKELL
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 1:17 E ENTERPRISE ST
Mailing Address - Street 2:
Mailing Address - City:GLEN LYON
Mailing Address - State:PA
Mailing Address - Zip Code:18617-1111
Mailing Address - Country:US
Mailing Address - Phone:570-417-3310
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKHILL SQ S
Practice Address - Street 2:
Practice Address - City:SUGARLOAF
Practice Address - State:PA
Practice Address - Zip Code:18249-1016
Practice Address - Country:US
Practice Address - Phone:570-778-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician