Provider Demographics
NPI:1649324203
Name:CORNELIUS, MARK WALTER (MS, MA LCPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WALTER
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:MS, MA LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1677
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1677
Mailing Address - Country:US
Mailing Address - Phone:208-664-1606
Mailing Address - Fax:208-664-9685
Practice Address - Street 1:421 E COEUR DALENE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-1704
Practice Address - Country:US
Practice Address - Phone:208-664-1606
Practice Address - Fax:208-664-9685
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 291101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor