Provider Demographics
NPI:1376437962
Name:CORLESS, CAMERON CHET
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:CHET
Last Name:CORLESS
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 1:3476 N DOUSMAN ST APT D
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1757
Mailing Address - Country:US
Mailing Address - Phone:608-345-4773
Mailing Address - Fax:
Practice Address - Street 1:11124 N CEDARBURG RD STE 150
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4362
Practice Address - Country:US
Practice Address - Phone:262-365-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health