Provider Demographics
NPI:1932750163
Name:CORELLA, MARTHA ALICIA (MSC, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:ALICIA
Last Name:CORELLA
Suffix:
Gender:F
Credentials:MSC, LPC
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:A
Other - Last Name:CORELLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1931 W WAVERLY ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1957
Mailing Address - Country:US
Mailing Address - Phone:520-981-3711
Mailing Address - Fax:
Practice Address - Street 1:1955 W GRANT RD STE F
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1147
Practice Address - Country:US
Practice Address - Phone:520-462-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC18413101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty