Provider Demographics
NPI:1871205047
Name:CORVALAN, BRENT LAWRENCE (MA)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:LAWRENCE
Last Name:CORVALAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1447
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0378
Mailing Address - Country:US
Mailing Address - Phone:360-261-6930
Mailing Address - Fax:
Practice Address - Street 1:152 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-261-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty