Provider Demographics
NPI:1942479381
Name:CLAIBORN, CORETHA MARIE (CSAC,MAC,SAP,LSATP)
Entity Type:Individual
Prefix:MRS
First Name:CORETHA
Middle Name:MARIE
Last Name:CLAIBORN
Suffix:
Gender:F
Credentials:CSAC,MAC,SAP,LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7053 OMALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234
Mailing Address - Country:US
Mailing Address - Phone:804-275-2340
Mailing Address - Fax:
Practice Address - Street 1:700 S. SYCAMORE STREET
Practice Address - Street 2:SUITE 6
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23234
Practice Address - Country:US
Practice Address - Phone:804-855-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710101777101YA0400X
VA0718000231101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)