1104546423 NPI number — MRS. CORRINE FAYE BUCHANAN MS, LMHC, NCC

Table of content: MRS. CORRINE FAYE BUCHANAN MS, LMHC, NCC (NPI 1104546423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104546423 NPI number — MRS. CORRINE FAYE BUCHANAN MS, LMHC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCHANAN
Provider First Name:
CORRINE
Provider Middle Name:
FAYE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LMHC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104546423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7901 4TH ST N STE 8198
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33702-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-212-0874
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TELEHEALTH/VIRTUAL SERVICES FROM 2601 NW 23RD BLVD
Provider Second Line Business Practice Location Address:
APT 162
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-212-0874
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH19538 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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