Provider Demographics
NPI:1457771289
Name:PATRICIA CORNELIOUS PHD
Entity Type:Organization
Organization Name:PATRICIA CORNELIOUS PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:636-697-6405
Mailing Address - Street 1:9229 BLUEBONNET BLVD
Mailing Address - Street 2:STE. B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2808
Mailing Address - Country:US
Mailing Address - Phone:225-766-7470
Mailing Address - Fax:225-766-7473
Practice Address - Street 1:9229 BLUEBONNET BLVD
Practice Address - Street 2:STE. B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2808
Practice Address - Country:US
Practice Address - Phone:225-766-7470
Practice Address - Fax:225-766-7473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty