Provider Demographics
NPI:1265519698
Name:CORNELISON, STEPHANI LEE (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:STEPHANI
Middle Name:LEE
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-9126
Mailing Address - Country:US
Mailing Address - Phone:706-616-3976
Mailing Address - Fax:
Practice Address - Street 1:206 THOMAS DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-9126
Practice Address - Country:US
Practice Address - Phone:706-616-3976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA376639331AOtherGEORGIA HEALTHY FAMILIES
GA513478088AMedicaid