Provider Demographics
NPI:1891359402
Name:CORBIN, ROGER L (MSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:CORBIN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N SWALLOW TAIL DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6103
Mailing Address - Country:US
Mailing Address - Phone:386-333-9717
Mailing Address - Fax:386-333-9718
Practice Address - Street 1:900 N SWALLOW TAIL DR STE 105
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6103
Practice Address - Country:US
Practice Address - Phone:386-333-9717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW135221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical