Provider Demographics
NPI:1932667037
Name:CORCORAN, AMBER MICHELLE (MAT, LAT, ATC, ITAT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MICHELLE
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:MAT, LAT, ATC, ITAT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:MICHELLE
Other - Last Name:PORTWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:2201 PEACHTREE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5355
Mailing Address - Country:US
Mailing Address - Phone:678-896-8934
Mailing Address - Fax:
Practice Address - Street 1:9310 SCOTT RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3417
Practice Address - Country:US
Practice Address - Phone:470-254-4230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0029402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer