1649204132 NPI number — MS. CAMILLA A CORNELIUS M.A., CCSW

Table of content: MS. CAMILLA A CORNELIUS M.A., CCSW (NPI 1649204132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649204132 NPI number — MS. CAMILLA A CORNELIUS M.A., CCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNELIUS
Provider First Name:
CAMILLA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649204132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 OLIVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27401-1532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-230-0647
Provider Business Mailing Address Fax Number:
336-230-1214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 OLIVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27401-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-230-0647
Provider Business Practice Location Address Fax Number:
336-230-1214
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C001349 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 24471 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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