Provider Demographics
NPI:1710488408
Name:CORNWALL, TIA (EDS, LPA)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:EDS, LPA
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 1023
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-1023
Mailing Address - Country:US
Mailing Address - Phone:540-314-0606
Mailing Address - Fax:
Practice Address - Street 1:209 SMITH AVE UNIT 1023
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28459-0180
Practice Address - Country:US
Practice Address - Phone:540-314-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2025-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1244890103TS0200X
NC6811103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool