Individual
TIA CORNWALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ED.S., LPA
Contact information
Practice address
4902 MAIN ST STE D, SHALLOTTE, NC 28470-4749
(910) 754-2289
Mailing address
PO BOX 1023, SHALLOTTE, NC 28459-1023
(540) 314-0606
Taxonomy
Speciality
Code
Description
License number
State
103TC2200X
Clinical Child & Adolescent Psychologist
Primary
6811
NC
103TS0200X
School Psychologist
1244890
NC
Other
Enumeration date
02/27/2018
Last updated
03/06/2026
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