Provider Demographics
NPI:1780891341
Name:CORLETT, MIRIAM THERESA (LCSW)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:THERESA
Last Name:CORLETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40950 CHAPEL WAY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4236
Mailing Address - Country:US
Mailing Address - Phone:510-226-6180
Mailing Address - Fax:
Practice Address - Street 1:40950 CHAPEL WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4236
Practice Address - Country:US
Practice Address - Phone:510-226-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical