Provider Demographics
NPI:1366102394
Name:CORNELIUS, GEORGIANNA
Entity type:Individual
Prefix:
First Name:GEORGIANNA
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 1:709 CHANCELLOR AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3066
Mailing Address - Country:US
Mailing Address - Phone:732-759-7888
Mailing Address - Fax:
Practice Address - Street 1:40 UNION AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3277
Practice Address - Country:US
Practice Address - Phone:201-253-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL063334001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty