Provider Demographics
NPI:1861982332
Name:MCCORKLE, TERESA DIANNE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:DIANNE
Last Name:MCCORKLE
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 1:52 BRAGG AVE
Mailing Address - Street 2:
Mailing Address - City:MUNFORDVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42765-9222
Mailing Address - Country:US
Mailing Address - Phone:270-537-3693
Mailing Address - Fax:844-688-4227
Practice Address - Street 1:52 BRAGG AVE
Practice Address - Street 2:
Practice Address - City:MUNFORDVILLE
Practice Address - State:KY
Practice Address - Zip Code:42765-9222
Practice Address - Country:US
Practice Address - Phone:270-537-3693
Practice Address - Fax:844-688-4227
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist