Healthcare Provider Details

I. General information

NPI: 1831506476
Provider Name (Legal Business Name): JUAN CARLOS CORDERO M.S., M.A., PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN CARLOS CORDERO M.A. , M.S, PSY.D

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 129-435-7375
  • Fax:
Mailing address:
  • Phone: 912-435-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002740
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2740
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002740
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: