Provider Demographics
NPI:1891259040
Name:CORNELIOUS, MICHAEL LEVELL JR (MA,60528786)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEVELL
Last Name:CORNELIOUS
Suffix:JR
Gender:M
Credentials:MA,60528786
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4426
Mailing Address - Country:US
Mailing Address - Phone:253-223-4221
Mailing Address - Fax:
Practice Address - Street 1:701 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4426
Practice Address - Country:US
Practice Address - Phone:253-223-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60528786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty