Provider Demographics
NPI:1982740601
Name:CORNELIUS, JOHN WATT (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WATT
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 EDMUNDS PLACE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016
Mailing Address - Country:US
Mailing Address - Phone:202-244-9635
Mailing Address - Fax:
Practice Address - Street 1:12900 MIDDLEBROOK ROAD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874
Practice Address - Country:US
Practice Address - Phone:301-588-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG119541041C0700X
DCLG500282541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical