Provider Demographics
NPI:1134524580
Name:CORNITA MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:CORNITA MENTAL HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PSYCH NP PROBIDER
Authorized Official - Prefix:
Authorized Official - First Name:CORDELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEKETIEN-TAWARI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN-BC, LNP
Authorized Official - Phone:703-869-5361
Mailing Address - Street 1:PO BOX 2692
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20195-0692
Mailing Address - Country:US
Mailing Address - Phone:703-869-5361
Mailing Address - Fax:703-957-3625
Practice Address - Street 1:1800 TOWN CENTER DR STE 420
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3240
Practice Address - Country:US
Practice Address - Phone:703-869-5361
Practice Address - Fax:703-957-3625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017137987163W00000X
VA0024165883363LF0000X, 363LP0808X, 363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1134524580OtherNPI (2)
VA11946976OtherCAQH NO.
VA1194827139OtherNPI (1)
VA0024165883OtherVA STATE BOARD OF NURSING-NP LICENSE