Provider Demographics
NPI:1063921740
Name:CHARLES CORBALLY PLLC
Entity type:Organization
Organization Name:CHARLES CORBALLY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORBALLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:802-281-3330
Mailing Address - Street 1:2 CHURCH ST STE 3G
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4457
Mailing Address - Country:US
Mailing Address - Phone:802-281-3330
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST STE 3G
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4457
Practice Address - Country:US
Practice Address - Phone:802-281-3330
Practice Address - Fax:802-540-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01170251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1028428Medicaid