Provider Demographics
NPI:1750631065
Name:CORBETT, TAKISHA M (PHD)
Entity type:Individual
Prefix:DR
First Name:TAKISHA
Middle Name:M
Last Name:CORBETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TAKISHA
Other - Middle Name:M
Other - Last Name:MCNEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1901 1ST AVE
Mailing Address - Street 2:STE 245
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-0311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 1ST AVENUE STE 245
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-9210
Practice Address - Country:US
Practice Address - Phone:858-964-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31413103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth