Provider Demographics
NPI:1154525673
Name:CORNELIUS, DONALD S (LCSW)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:S
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 TALL OAK DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-7115
Mailing Address - Country:US
Mailing Address - Phone:631-423-0773
Mailing Address - Fax:
Practice Address - Street 1:136 WOODBURY RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1411
Practice Address - Country:US
Practice Address - Phone:516-692-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR017761-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN00321Medicare ID - Type Unspecified