Provider Demographics
NPI:1255605762
Name:CORNELIUSSEN, STEPHANIE J (PSYD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:CORNELIUSSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-3100
Mailing Address - Fax:
Practice Address - Street 1:100 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1929
Practice Address - Country:US
Practice Address - Phone:701-234-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16885Medicaid