Healthcare Provider Details

I. General information

NPI: 1710488408
Provider Name (Legal Business Name): TIA CORNWALL ED.S., LPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4902 MAIN ST STE D
SHALLOTTE NC
28470-4749
US

IV. Provider business mailing address

PO BOX 1023
SHALLOTTE NC
28459-1023
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-2289
  • Fax:
Mailing address:
  • Phone: 540-314-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6811
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1244890
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: