Provider Demographics
NPI:1073362612
Name:CORBETT, KYWANA RENEE (LRT, CTRS)
Entity type:Individual
Prefix:
First Name:KYWANA
Middle Name:RENEE
Last Name:CORBETT
Suffix:
Gender:F
Credentials:LRT, CTRS
Other - Prefix:
Other - First Name:KYWANA
Other - Middle Name:RENEE
Other - Last Name:CORBETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LRT, CTRS
Mailing Address - Street 1:2400 ALSTONBURG AVE # A
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9384
Mailing Address - Country:US
Mailing Address - Phone:910-515-3492
Mailing Address - Fax:
Practice Address - Street 1:2400 ALSTONBURG AVE # A
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-9384
Practice Address - Country:US
Practice Address - Phone:910-515-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4620225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist