Provider Demographics
NPI:1306060108
Name:CORK, CHRISTINE ROGERS (PSYD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:ROGERS
Last Name:CORK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CHRISTINE
Other - Middle Name:LYNN
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 1408
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-1408
Mailing Address - Country:US
Mailing Address - Phone:319-365-3993
Mailing Address - Fax:319-364-0116
Practice Address - Street 1:1730 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5433
Practice Address - Country:US
Practice Address - Phone:319-365-3993
Practice Address - Fax:319-364-0116
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00970103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1306060108OtherWELLMARK
IA1306060108Medicaid