Provider Demographics
NPI:1396340469
Name:CORREA, CARLOS LUIS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:LUIS
Last Name:CORREA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9924 BENNINGTON CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8214
Mailing Address - Country:US
Mailing Address - Phone:407-271-7989
Mailing Address - Fax:
Practice Address - Street 1:5201 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-8208
Practice Address - Country:US
Practice Address - Phone:407-646-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW150491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical