Provider Demographics
NPI:1033499173
Name:CORNELIUS, CHIQUITHA
Entity Type:Individual
Prefix:
First Name:CHIQUITHA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 S 11TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4736
Mailing Address - Country:US
Mailing Address - Phone:574-274-0152
Mailing Address - Fax:
Practice Address - Street 1:3130 S 11TH ST STE 105
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4736
Practice Address - Country:US
Practice Address - Phone:574-274-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015882102L00000X, 103T00000X, 103TM1800X, 103TP0814X, 103TP2701X, 103TB0200X, 102L00000X
MI6801095307104100000X
MI68301017882084P0800X, 208D00000X
253Z00000X, 372500000X, 372600000X, 374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No253Z00000XAgenciesIn Home Supportive Care
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice