Provider Demographics
NPI:1982971248
Name:CORRALES, LOURDES CECILIA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:CECILIA
Last Name:CORRALES
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11527 WOODGLEN WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7453
Mailing Address - Country:US
Mailing Address - Phone:904-262-3197
Mailing Address - Fax:
Practice Address - Street 1:9471 BAYMEADOWS RD
Practice Address - Street 2:SUITE 304
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7932
Practice Address - Country:US
Practice Address - Phone:904-733-8255
Practice Address - Fax:904-733-5034
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLSA 8201235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA 8201OtherDOH SPEECH LANGUAGE PATHOLOGIST LICENSE