Provider Demographics
NPI:1881777456
Name:POULSEN, CORIE J (LCPC)
Entity type:Individual
Prefix:MRS
First Name:CORIE
Middle Name:J
Last Name:POULSEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HANSEN ST E
Mailing Address - Street 2:STE 9
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-7941
Mailing Address - Fax:208-733-5415
Practice Address - Street 1:140 HANSEN ST E
Practice Address - Street 2:STE 9
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-7941
Practice Address - Fax:208-733-5415
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-116101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00010016857OtherBLUE SHIELD
IDQ5795OtherBLUE CROSS