Healthcare Provider Details

I. General information

NPI: 1528108099
Provider Name (Legal Business Name): CORNELIA WENZE ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LANIER AVE W STE 103B
FAYETTEVILLE GA
30214-7640
US

IV. Provider business mailing address

2600 MAIN ST UNIT 120
PORTERDALE GA
30070-3305
US

V. Phone/Fax

Practice location:
  • Phone: 404-800-4002
  • Fax: 404-393-5698
Mailing address:
  • Phone: 404-618-4843
  • Fax: 470-441-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7527
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number010382
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: