Provider Demographics
NPI:1922324573
Name:DENNIS, CORY BRAD (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:BRAD
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2179 JFSB
Mailing Address - Street 2:BRIGHAM YOUNG UNIVERSITY
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602
Mailing Address - Country:US
Mailing Address - Phone:518-956-1901
Mailing Address - Fax:
Practice Address - Street 1:2179 JFSB
Practice Address - Street 2:BRIGHAM YOUNG UNIVERSITY
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-422-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5947893-35011041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical