Healthcare Provider Details

I. General information

NPI: 1366217986
Provider Name (Legal Business Name): WILLIAM TYLER CORNELIUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2023
Last Update Date: 11/24/2023
Certification Date: 11/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CRESTLINE AVE
CINCINNATI OH
45205-2207
US

IV. Provider business mailing address

330 CRESTLINE AVE
CINCINNATI OH
45205-2207
US

V. Phone/Fax

Practice location:
  • Phone: 513-446-5756
  • Fax:
Mailing address:
  • Phone: 513-446-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: