Provider Demographics
NPI:1447721352
Name:CORLEY, MYRA (LSW)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:CORLEY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 ENTERPRISE DR NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-8706
Mailing Address - Country:US
Mailing Address - Phone:330-787-0955
Mailing Address - Fax:
Practice Address - Street 1:4930 ENTERPRISE DR NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-8706
Practice Address - Country:US
Practice Address - Phone:330-787-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168199324500000X
OH1904190104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility