Provider Demographics
NPI:1700425964
Name:CORPREW, TABRIA
Entity Type:Individual
Prefix:
First Name:TABRIA
Middle Name:
Last Name:CORPREW
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 1:101 BLUE MOON CROSSING
Mailing Address - Street 2:SUITE 3, UNIT 114
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:912-325-9855
Mailing Address - Fax:912-219-2285
Practice Address - Street 1:101 BLUE MOON CROSSING STE. 3
Practice Address - Street 2:UNIT 114
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-682-1383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011310101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional