Provider Demographics
NPI:1982493888
Name:CORKWELL, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CORKWELL
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N OAK ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1218
Practice Address - Country:US
Practice Address - Phone:260-459-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-339271106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician