Individual
STEPHANIE J CORNELIUSSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSYD
Contact information
Practice address
100 4TH ST S, FARGO, ND 58103-1929
(701) 234-3100
Mailing address
PO BOX 2168, FARGO, ND 58107-2168
(701) 234-3100
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
16885
—
ND
Enumeration date
03/01/2012
Last updated
07/26/2012
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