Provider Demographics
NPI:1609228048
Name:CORNELIUSSEN, SCOTT (ATC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:CORNELIUSSEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 21ST AVE S
Mailing Address - Street 2:APT. #201
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7787
Mailing Address - Country:US
Mailing Address - Phone:701-361-4730
Mailing Address - Fax:
Practice Address - Street 1:5200 21ST AVE S
Practice Address - Street 2:APT. #201
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7787
Practice Address - Country:US
Practice Address - Phone:701-361-4730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer