Healthcare Provider Details

I. General information

NPI: 1265519698
Provider Name (Legal Business Name): STEPHANI LEE CORNELISON PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 THOMAS DR
LAGRANGE GA
30240-9126
US

IV. Provider business mailing address

206 THOMAS DR
LAGRANGE GA
30240-9126
US

V. Phone/Fax

Practice location:
  • Phone: 706-616-3976
  • Fax:
Mailing address:
  • Phone: 706-616-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003562
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: