Provider Demographics
NPI:1861822637
Name:CORNELIUS, TAMMY JANE (MA, LPC, CSOTS)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JANE
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:MA, LPC, CSOTS
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:JANE
Other - Last Name:KAFKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, CSOTS
Mailing Address - Street 1:1049 E NEWELL ST
Mailing Address - Street 2:PO BOX 867
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-8795
Mailing Address - Country:US
Mailing Address - Phone:231-689-7330
Mailing Address - Fax:
Practice Address - Street 1:1049 E NEWELL ST
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8795
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010721101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health