Provider Demographics
NPI:1821601469
Name:CORNELIUS, LLEWELLYN (PHD, LCSW)
Entity Type:Individual
Prefix:PROF
First Name:LLEWELLYN
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HILLARY LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6699
Mailing Address - Country:US
Mailing Address - Phone:443-934-5034
Mailing Address - Fax:
Practice Address - Street 1:306 GATEHOUSE LN APT H
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-2838
Practice Address - Country:US
Practice Address - Phone:443-934-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11763104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty