Basic Information
| Provider Information | |||||||||
| NPI: | 1215463674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLUSKY | ||||||||
| FirstName: | CORIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STAPLES | ||||||||
| OtherFirstName: | CORIE | ||||||||
| OtherMiddleName: | BETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 118 W UNION ST | ||||||||
| Address2: | |||||||||
| City: | MUNFORDVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427658911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708425268 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 W UNION ST | ||||||||
| Address2: | |||||||||
| City: | MUNFORDVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427658911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708425268 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.