Provider Demographics
NPI:1194741884
Name:CORLEY, GWEN HUMPHREY (LCSW)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:HUMPHREY
Last Name:CORLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E CORK ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-5023
Mailing Address - Country:US
Mailing Address - Phone:540-722-0562
Mailing Address - Fax:540-722-1081
Practice Address - Street 1:116 E CORK ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-5023
Practice Address - Country:US
Practice Address - Phone:540-722-0562
Practice Address - Fax:540-722-1081
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040022011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA088773OtherOPTIMA
VA8905983Medicaid
VA8905983Medicaid