=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821601469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LLEWELLYN CORNELIUS PH.D., LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2020
-----------------------------------------------------
Last Update Date | 08/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 GATEHOUSE LN APT H
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-934-5034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 HILLARY LN
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-6699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-934-5034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 11763
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------