Provider Demographics
NPI:1841896081
Name:CORLEY, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CORLEY
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 1:5300 BRICKLEBERRY WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-4068
Mailing Address - Country:US
Mailing Address - Phone:678-886-0999
Mailing Address - Fax:
Practice Address - Street 1:5300 BRICKLEBERRY WAY STE 206
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-4068
Practice Address - Country:US
Practice Address - Phone:678-886-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006703101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003239367AMedicaid