Provider Demographics
NPI:1588149363
Name:CORREA, MICHELLE M (SC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:CORREA
Suffix:
Gender:F
Credentials:SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108-22 51ST AVE
Mailing Address - Street 2:3FL
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-844-3869
Mailing Address - Fax:
Practice Address - Street 1:3711 35TH AVE STE 3C
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11101-1441
Practice Address - Country:US
Practice Address - Phone:718-706-7500
Practice Address - Fax:718-706-9595
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY114723103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator