Provider Demographics
NPI:1093180770
Name:CORNELIUS, MANDY (LMSW)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2155
Mailing Address - Country:US
Mailing Address - Phone:602-406-8270
Mailing Address - Fax:602-406-0680
Practice Address - Street 1:625 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2155
Practice Address - Country:US
Practice Address - Phone:602-406-8270
Practice Address - Fax:602-406-0680
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-11979104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker