Provider Demographics
NPI:1164064416
Name:CORNWALL, AUBREY
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6552 MURRAY AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3052
Mailing Address - Country:US
Mailing Address - Phone:330-323-5669
Mailing Address - Fax:
Practice Address - Street 1:8809B CINCINNATI DAYTON RD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-3134
Practice Address - Country:US
Practice Address - Phone:330-323-5669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000411691104100000X, 1041S0200X
OH1041S0200X
106S00000X
OHC.2204433101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician