Provider Demographics
NPI:1770560104
Name:CORNELIUS, SCOTT CARDON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:CARDON
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 LOCUST ST STE 4
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2045
Mailing Address - Country:US
Mailing Address - Phone:413-341-5096
Mailing Address - Fax:
Practice Address - Street 1:51 LOCUST ST STE 4
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2045
Practice Address - Country:US
Practice Address - Phone:413-341-5096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9171103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN