Healthcare Provider Details

I. General information

NPI: 1356445944
Provider Name (Legal Business Name): CORNELIA H. SWAYZE LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4387 LEISURE TIME DRIVE
DIAMONDHEAD MS
39525
US

IV. Provider business mailing address

7619 FAIRWAY DRIVE
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 Code1041C0700X
TaxonomyClinical Social Worker
License NumberC4648
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: