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General NPI Number Information
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NPI Number | 1710488408
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Entity Type | Individual
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Provider Name | TIA CORNWALL ED.S., LPA
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Gender | Female
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Dates
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Enumeration Date | 02/27/2018
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Last Update Date | 10/19/2025
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Provider Practice Location Address
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Address Line | 209 SMITH AVE UNIT 1023
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City | SHALLOTTE
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State | NC
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Zip | 28459-0180
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Country | US
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Telephone | 540-314-0606
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1023
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City | SHALLOTTE
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State | NC
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Zip | 28459-1023
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Country | US
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Telephone | 540-314-0606
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 1244890
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 6811
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License Number State | NC
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