Healthcare Provider Details

I. General information

NPI: 1720575699
Provider Name (Legal Business Name): SUSAN CORNELIUS-POWERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 FARAON ST
SAINT JOSEPH MO
64506-3044
US

IV. Provider business mailing address

2303 VILLAGE DR
SAINT JOSEPH MO
64506-4954
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-6444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: