Provider Demographics
NPI:1043964414
Name:CORLEY, CHRISTOPHER JEROME I
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JEROME
Last Name:CORLEY
Suffix:I
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 1:9511 TANZANITE AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-8093
Mailing Address - Country:US
Mailing Address - Phone:442-247-9567
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2627
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:800-218-6006
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician