Provider Demographics
NPI:1427717909
Name:CORREA, IDALIE (MPSY, LPA)
Entity type:Individual
Prefix:
First Name:IDALIE
Middle Name:
Last Name:CORREA
Suffix:
Gender:F
Credentials:MPSY, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-6106
Mailing Address - Country:US
Mailing Address - Phone:817-897-4518
Mailing Address - Fax:
Practice Address - Street 1:1106 SANTA FE TRL
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3063
Practice Address - Country:US
Practice Address - Phone:972-863-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37381103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling