Provider Demographics
NPI:1053998674
Name:MCCLOUD, CORISSA
Entity type:Individual
Prefix:
First Name:CORISSA
Middle Name:
Last Name:MCCLOUD
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 1:400 BELMONT PL SE UNIT 2338
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2055
Mailing Address - Country:US
Mailing Address - Phone:850-227-6904
Mailing Address - Fax:
Practice Address - Street 1:2600 COMPASS RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8001
Practice Address - Country:US
Practice Address - Phone:877-787-3430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002316224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant