Provider Demographics
NPI:1447871363
Name:CORNELIUS, COLLEEN CRAWFORD (PHD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:CRAWFORD
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 QUEENSWAY DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-1009
Mailing Address - Country:US
Mailing Address - Phone:859-533-3275
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE 4TH FLOOR WING D
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251781103TS0200X
KY268918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool