Provider Demographics
NPI:1760684450
Name:LONG, CORNELIA HAWKINS (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CORNELIA
Middle Name:HAWKINS
Last Name:LONG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2544 PORT POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-1464
Mailing Address - Country:US
Mailing Address - Phone:703-409-1822
Mailing Address - Fax:703-670-8923
Practice Address - Street 1:2544 PORT POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-1464
Practice Address - Country:US
Practice Address - Phone:703-409-1822
Practice Address - Fax:703-670-8923
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist