Provider Demographics
NPI:1972537264
Name:COREY, MARK ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:COREY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74103
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-5103
Mailing Address - Country:US
Mailing Address - Phone:530-759-1277
Mailing Address - Fax:
Practice Address - Street 1:231 C ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4521
Practice Address - Country:US
Practice Address - Phone:530-759-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14130103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist