Provider Demographics
NPI:1336617935
Name:CORCORAN, CHRISTINE A
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:CORCORAN
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 1:434 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2342
Mailing Address - Country:US
Mailing Address - Phone:513-354-7100
Mailing Address - Fax:513-354-7115
Practice Address - Street 1:434 SCOTT ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-2342
Practice Address - Country:US
Practice Address - Phone:513-354-7100
Practice Address - Fax:513-354-7115
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1303134104100000X
KY2537211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00000OtherLICENSURE BOARD