Provider Demographics
NPI:1053618702
Name:MACEDON, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:MACEDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5870 ARLINGTON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2037
Mailing Address - Country:US
Mailing Address - Phone:951-683-6596
Mailing Address - Fax:951-683-4239
Practice Address - Street 1:1604 S SANTA FE AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5060
Practice Address - Country:US
Practice Address - Phone:951-654-2026
Practice Address - Fax:951-654-9927
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor