Provider Demographics
NPI:1295280501
Name:KOREN, PHYLLIS
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:KOREN
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 1:12101 MIDDLECOFF DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2692
Mailing Address - Country:US
Mailing Address - Phone:804-317-9053
Mailing Address - Fax:804-681-0502
Practice Address - Street 1:12101 MIDDLECOFF DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-2692
Practice Address - Country:US
Practice Address - Phone:804-317-9053
Practice Address - Fax:804-681-0502
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4341235Z00000X
AK529235Z00000X
VA2202005090235Z00000X
FLSA4758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist