Provider Demographics
NPI:1730582628
Name:CORNELL, ALICIA CORNELL (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:ALICIA CORNELL
Middle Name:
Last Name:CORNELL
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 CURTISS CT
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-2473
Mailing Address - Country:US
Mailing Address - Phone:440-974-2272
Mailing Address - Fax:
Practice Address - Street 1:6465 CURTISS CT
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-2473
Practice Address - Country:US
Practice Address - Phone:440-974-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3175611103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool