Provider Demographics
NPI:1730453747
Name:ROAN, COREY SUMMERLIN (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:COREY
Middle Name:SUMMERLIN
Last Name:ROAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5057 FRINK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1212
Mailing Address - Country:US
Mailing Address - Phone:757-288-9512
Mailing Address - Fax:
Practice Address - Street 1:5057 FRINK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-1212
Practice Address - Country:US
Practice Address - Phone:757-288-9512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005572225XP0019X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119005572OtherLISCENSE NUMBER