Provider Demographics
NPI:1780992529
Name:CONKLIN, CORRINE IDA
Entity type:Individual
Prefix:
First Name:CORRINE
Middle Name:IDA
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 HEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1155
Mailing Address - Country:US
Mailing Address - Phone:813-205-1906
Mailing Address - Fax:
Practice Address - Street 1:2804 HEATHERWOOD DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1155
Practice Address - Country:US
Practice Address - Phone:813-205-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist