Provider Demographics
NPI:1700423886
Name:PRIAM, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:PRIAM
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 1:1458 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3222
Mailing Address - Country:US
Mailing Address - Phone:347-768-0485
Mailing Address - Fax:
Practice Address - Street 1:10470 QUEENS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3694
Practice Address - Country:US
Practice Address - Phone:718-275-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP102927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health