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NPI Code Detail

MEDICARE: AMANDA VIRGINIA CORNELIUS LPC

MEDICARE: AMANDA VIRGINIA CORNELIUS LPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor00765MN
2101YP2500XProfessional Counselor

General Provider Information

NPI Number : 1942593561
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA VIRGINIA CORNELIUS LPC
Provider Business Mailing Address
First Line : 1405 SILVER LAKE RD NW
Second Line :
City : NEW BRIGHTON
State : MN
Zip : 55112-9301
Country : US
Telephone Number : 651-895-3624
Fax Number :
Provider Business Practice Location Address
First Line : 1405 SILVER LAKE RD NW
Second Line :
City : NEW BRIGHTON
State : MN
Zip : 55112-9301
Country : US
Telephone Number : 651-895-3624
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2011
Last Update Date : 05/17/2011

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Directions to “ AMANDA VIRGINIA CORNELIUS LPC” Practice Location

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