Provider Demographics
NPI:1922677699
Name:CORNELISSE, LAURA JANE (MS, CF-SLP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JANE
Last Name:CORNELISSE
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W GROVE PKWY APT 313
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4508
Mailing Address - Country:US
Mailing Address - Phone:406-830-6742
Mailing Address - Fax:
Practice Address - Street 1:202 N SYCAMORE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6150
Practice Address - Country:US
Practice Address - Phone:480-472-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist