Provider Demographics
NPI:1841933058
Name:KNEEDLER, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:KNEEDLER
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 1:325 S ASH ST
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-4628
Mailing Address - Country:US
Mailing Address - Phone:620-515-5897
Mailing Address - Fax:
Practice Address - Street 1:555 BELAIRE AVE STE 350
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4789
Practice Address - Country:US
Practice Address - Phone:804-207-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
VA0704017011101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator