Provider Demographics
NPI:1235449273
Name:CORNELIA SWAYZE, LCSW, LLC
Entity Type:Organization
Organization Name:CORNELIA SWAYZE, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAYZE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:228-363-2211
Mailing Address - Street 1:7619 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3436
Mailing Address - Country:US
Mailing Address - Phone:228-363-2211
Mailing Address - Fax:228-255-6494
Practice Address - Street 1:4423 LEISURE TIME DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3221
Practice Address - Country:US
Practice Address - Phone:228-363-2211
Practice Address - Fax:228-255-6494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC4648104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800000209Medicare PIN