Provider Demographics
NPI:1942823760
Name:CORELLAS, DOMINIQUE LEA
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LEA
Last Name:CORELLAS
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 1:2396 NW KINGS BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3984
Mailing Address - Country:US
Mailing Address - Phone:541-224-1684
Mailing Address - Fax:
Practice Address - Street 1:2396 NW KINGS BLVD STE 201
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3984
Practice Address - Country:US
Practice Address - Phone:541-224-1684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program