Basic Information
| Provider Information | |||||||||
| NPI: | 1083213169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.ED, QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27193 BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | OLMSTED TWP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441381061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405674009 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10427 DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441021645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165216511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health | 101YM0800X | C.2002657-TRNE | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1083213169 | 05 | OH | MEDICAID |