Provider Demographics
NPI:1821781261
Name:CORNELISON, QUENTIN LEON
Entity Type:Individual
Prefix:
First Name:QUENTIN
Middle Name:LEON
Last Name:CORNELISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 SOUTHPARK DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-2094
Mailing Address - Country:US
Mailing Address - Phone:205-961-4726
Mailing Address - Fax:
Practice Address - Street 1:1820 SOUTHPARK DR
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-2094
Practice Address - Country:US
Practice Address - Phone:205-961-4726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician