Provider Demographics
NPI:1063600625
Name:WILKES, COREY SAE-JIN (LSW)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:SAE-JIN
Last Name:WILKES
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 POTH RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1324
Mailing Address - Country:US
Mailing Address - Phone:614-751-9068
Mailing Address - Fax:614-751-9130
Practice Address - Street 1:4440 POTH RD
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-1324
Practice Address - Country:US
Practice Address - Phone:614-751-9068
Practice Address - Fax:614-751-9130
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-0028492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker