Provider Demographics
NPI:1215140470
Name:CORNELL, SARA (LMSW)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:CORNELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4513
Mailing Address - Country:US
Mailing Address - Phone:616-459-0255
Mailing Address - Fax:616-242-6057
Practice Address - Street 1:213 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4557
Practice Address - Country:US
Practice Address - Phone:616-459-0255
Practice Address - Fax:616-242-6057
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20351Medicare UPIN
MI750910910Medicare UPIN