Healthcare Provider Details

I. General information

NPI: 1710896188
Provider Name (Legal Business Name): CORDERIUS ALPHONSO COWANS LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REMOTE
REMOTE NC
27407
US

IV. Provider business mailing address

4017 ARDSLEY CT
GREENSBORO NC
27407-7869
US

V. Phone/Fax

Practice location:
  • Phone: 773-309-1683
  • Fax:
Mailing address:
  • Phone: 336-954-0944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: