Provider Demographics
NPI:1235607136
Name:SMITH, CORNEILUS NATHANIEL (MS, MFT)
Entity Type:Individual
Prefix:MR
First Name:CORNEILUS
Middle Name:NATHANIEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:MR
Other - First Name:CORNEILUS
Other - Middle Name:NATHANIEL
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, MFT
Mailing Address - Street 1:6173 UPLAND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-2428
Mailing Address - Country:US
Mailing Address - Phone:267-343-2080
Mailing Address - Fax:
Practice Address - Street 1:6173 UPLAND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-2428
Practice Address - Country:US
Practice Address - Phone:267-343-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health