Provider Demographics
NPI:1497479752
Name:CORNELIUS, OLIVIA RAE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAE
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 1:220 N PARK BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6900
Mailing Address - Country:US
Mailing Address - Phone:817-796-6860
Mailing Address - Fax:
Practice Address - Street 1:220 N PARK BLVD STE 112
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6900
Practice Address - Country:US
Practice Address - Phone:817-796-6860
Practice Address - Fax:817-796-2895
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-233860106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician