Provider Demographics
NPI:1548286735
Name:CORYELL, TODD (PHD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:
Last Name:CORYELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1857 23RD AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-2913
Mailing Address - Country:US
Mailing Address - Phone:206-329-8350
Mailing Address - Fax:425-412-3281
Practice Address - Street 1:1857 23RD AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-2913
Practice Address - Country:US
Practice Address - Phone:206-329-8350
Practice Address - Fax:425-412-3281
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPY00001092OtherLICENSE NUMBER
WA108304Medicare UPIN