Provider Demographics
NPI:1124583513
Name:MUNROE, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:MUNROE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 SONOMA HWY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-7100
Mailing Address - Country:US
Mailing Address - Phone:707-327-0909
Mailing Address - Fax:
Practice Address - Street 1:4415 SONOMA HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-7100
Practice Address - Country:US
Practice Address - Phone:707-327-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-10
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA119150104100000X
1191501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker