Healthcare Provider Details

I. General information

NPI: 1770560104
Provider Name (Legal Business Name): SCOTT CARDON CORNELIUS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/18/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N MAIN ST
LEEDS MA
01053-9764
US

IV. Provider business mailing address

421 N MAIN ST
LEEDS MA
01053-9764
US

V. Phone/Fax

Practice location:
  • Phone: 413-584-4040
  • Fax:
Mailing address:
  • Phone: 413-584-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9171
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: