Healthcare Provider Details

I. General information

NPI: 1134524580
Provider Name (Legal Business Name): CORNITA MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TOWN CENTER DR STE 420
RESTON VA
20190-3240
US

IV. Provider business mailing address

PO BOX 2692
RESTON VA
20195-0692
US

V. Phone/Fax

Practice location:
  • Phone: 703-869-5361
  • Fax: 703-957-3625
Mailing address:
  • Phone: 703-869-5361
  • Fax: 703-957-3625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0017137987
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024165883
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024165883
License Number StateVA

VIII. Authorized Official

Name: CORDELIA NIEKETIEN-TAWARI
Title or Position: CEO/PSYCH NP PROBIDER
Credential: DNP, APRN-BC, LNP
Phone: 703-869-5361