Provider Demographics
NPI:1831506476
Name:CORDERO, JUAN CARLOS (MS, MA, PSYD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:CORDERO
Suffix:
Gender:M
Credentials:MS, MA, PSYD
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:CORDERO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA , MS, PSYD
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-7375
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:129-435-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
PR002740101YM0800X, 103TC0700X
PR2740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health