Provider Demographics
NPI:1215188479
Name:CORNELISON, TANJA DAWN (LPC)
Entity type:Individual
Prefix:
First Name:TANJA
Middle Name:DAWN
Last Name:CORNELISON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-3076
Mailing Address - Country:US
Mailing Address - Phone:208-604-0155
Mailing Address - Fax:
Practice Address - Street 1:210 E CENTER ST STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6326
Practice Address - Country:US
Practice Address - Phone:208-234-2600
Practice Address - Fax:208-234-2800
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3452101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor