Provider Demographics
NPI:1104633957
Name:CORNELIUS, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 WALTHER AVE APT C5
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-1762
Mailing Address - Country:US
Mailing Address - Phone:814-566-2606
Mailing Address - Fax:
Practice Address - Street 1:10264 BALTIMORE NATIONAL PIKE STE B
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3609
Practice Address - Country:US
Practice Address - Phone:410-908-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30072104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker