Provider Demographics
NPI:1013630813
Name:ONSTAD, KORRINA NICOLE
Entity Type:Individual
Prefix:
First Name:KORRINA
Middle Name:NICOLE
Last Name:ONSTAD
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 1:15274 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3391
Mailing Address - Country:US
Mailing Address - Phone:623-414-2253
Mailing Address - Fax:
Practice Address - Street 1:4170 N 108TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5469
Practice Address - Country:US
Practice Address - Phone:206-369-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21-171056106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician