Healthcare Provider Details

I. General information

NPI: 1235449273
Provider Name (Legal Business Name): CORNELIA SWAYZE, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 LEISURE TIME DR
DIAMONDHEAD MS
39525-3221
US

IV. Provider business mailing address

7619 FAIRWAY DR
DIAMONDHEAD MS
39525-3436
US

V. Phone/Fax

Practice location:
  • Phone: 228-363-2211
  • Fax: 228-255-6494
Mailing address:
  • Phone: 228-363-2211
  • Fax: 228-255-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC4648
License Number StateMS

VIII. Authorized Official

Name: CORNELIA SWAYZE
Title or Position: OWNER
Credential: LCSW
Phone: 228-363-2211