Provider Demographics
NPI:1720453764
Name:CORNELIUS, KENNETH W (MA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:W
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 LINE AVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4621
Mailing Address - Country:US
Mailing Address - Phone:318-828-1455
Mailing Address - Fax:
Practice Address - Street 1:1513 LINE AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4621
Practice Address - Country:US
Practice Address - Phone:318-828-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator