Provider Demographics
NPI:1508615204
Name:PURNELL, COREY ISAIAH (CSAC SUPERVISEE)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:ISAIAH
Last Name:PURNELL
Suffix:
Gender:M
Credentials:CSAC SUPERVISEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10736 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5122
Mailing Address - Country:US
Mailing Address - Phone:757-358-8250
Mailing Address - Fax:
Practice Address - Street 1:5105Q BACKLICK RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-6072
Practice Address - Country:US
Practice Address - Phone:571-517-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0709025467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)