Provider Demographics
NPI:1730441205
Name:CORPOLONGO, CARLY (LMSW)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:CORPOLONGO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S ADAMS RD STE 235
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6931
Mailing Address - Country:US
Mailing Address - Phone:734-674-7199
Mailing Address - Fax:
Practice Address - Street 1:725 S ADAMS RD STE 235
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6931
Practice Address - Country:US
Practice Address - Phone:734-674-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010878941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical