Provider Demographics
NPI:1265988893
Name:CORLEY, KELLY RODRIGUEZ
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RODRIGUEZ
Last Name:CORLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:CORLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:204 G STREET
Mailing Address - Street 2:204 G STREET
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-775-8232
Mailing Address - Fax:
Practice Address - Street 1:204 G ST
Practice Address - Street 2:204 G ST
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-775-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA660001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical