Provider Demographics
NPI:1144523143
Name:SURATT, CORY A
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:A
Last Name:SURATT
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 1:1210 W 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2348
Mailing Address - Country:US
Mailing Address - Phone:617-548-7119
Mailing Address - Fax:
Practice Address - Street 1:2145 CENTENNIAL PLZ
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2421
Practice Address - Country:US
Practice Address - Phone:541-485-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1195101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor