Provider Demographics
NPI:1225695729
Name:CORNELIUS, ANNIE (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4005 N PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38152-4220
Mailing Address - Country:US
Mailing Address - Phone:901-834-7312
Mailing Address - Fax:
Practice Address - Street 1:4005 N PARK LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-4220
Practice Address - Country:US
Practice Address - Phone:901-834-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN281103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst