Basic Information
| Provider Information | |||||||||
| NPI: | 1720690449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDERO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Credential: | ED.M., LAPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 NORTH AVE NE APT 4315 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123064986 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 GWINNETT DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782092394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | APC007562 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.