Provider Demographics
NPI:1467467894
Name:CORCORAN, KATHERINE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 N FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1806
Mailing Address - Country:US
Mailing Address - Phone:773-235-0379
Mailing Address - Fax:
Practice Address - Street 1:2434 N FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1806
Practice Address - Country:US
Practice Address - Phone:773-235-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2032057103T00000X
IL071005494103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001626099OtherBCBS
IL196774000OtherMIS # BCBS/MAG
IL680016241OtherR & R MEDICARE
26889122OtherTRICARE
WI39747700Medicaid
IL196774000OtherMIS # BCBS/MAG
WI39747700Medicaid