Healthcare Provider Details

I. General information

NPI: 1942593561
Provider Name (Legal Business Name): AMANDA VIRGINIA CORNELIUS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-9301
US

IV. Provider business mailing address

1405 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-9301
US

V. Phone/Fax

Practice location:
  • Phone: 651-895-3624
  • Fax:
Mailing address:
  • Phone: 651-895-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00765
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: