Provider Demographics
NPI:1194566943
Name:CORNELL, KAMERYN BROOKE
Entity type:Individual
Prefix:
First Name:KAMERYN
Middle Name:BROOKE
Last Name:CORNELL
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 1:512 NORTHWESTERN DR
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1435
Mailing Address - Country:US
Mailing Address - Phone:734-915-1911
Mailing Address - Fax:
Practice Address - Street 1:1434 W CHICAGO BLVD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-8727
Practice Address - Country:US
Practice Address - Phone:517-507-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician