Provider Demographics
NPI:1194218909
Name:CORNWALL, RICHARD WARD (LCSW)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WARD
Last Name:CORNWALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 APPLEBEE ST
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-3035
Mailing Address - Country:US
Mailing Address - Phone:847-381-0345
Mailing Address - Fax:630-859-2994
Practice Address - Street 1:118 APPLEBEE ST
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-3035
Practice Address - Country:US
Practice Address - Phone:847-381-0345
Practice Address - Fax:630-859-2994
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490273051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1821151119Medicaid