Provider Demographics
NPI:1881287118
Name:CORNELIUS, RIVA (LCSW)
Entity type:Individual
Prefix:
First Name:RIVA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 43RD AVE.
Mailing Address - Street 2:SUITE D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:601-215-5545
Mailing Address - Fax:
Practice Address - Street 1:1403 43RD AVE.
Practice Address - Street 2:SUITE D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3950
Practice Address - Country:US
Practice Address - Phone:601-215-5545
Practice Address - Fax:228-241-0326
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical