=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114001757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES DARRELL CORNISH LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 INDEPENDENCE BLVD SUITE 138
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-5493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-437-6142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 941 BAJA CT
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23456-4279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-721-0347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701000889
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------