Healthcare Provider Details

I. General information

NPI: 1144157223
Provider Name (Legal Business Name): CORNERSTONE HEALTH & WELLNESS CLINIC OF TENNESSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10634 THREE WISHES DR
OLIVE BRANCH MS
38654-8753
US

IV. Provider business mailing address

10634 THREE WISHES DR
OLIVE BRANCH MS
38654-8753
US

V. Phone/Fax

Practice location:
  • Phone: 901-406-6705
  • Fax:
Mailing address:
  • Phone: 901-406-6705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELICA LUCAS
Title or Position: CEO/OWNER
Credential: LMSW
Phone: 901-406-6705