Basic Information
| Provider Information | |||||||||
| NPI: | 1710382916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDER | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | FRANK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 EVERGREEN DR | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306557354 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 GWINNETT DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782092394 | ||||||||
| FaxNumber: | 6782126343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2014 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MSW006379 | GA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | MSW006379 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.