Provider Demographics
NPI:1386155588
Name:CORNELL, KATELYN JANELLE (LMSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:JANELLE
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 1:205 WATER ST
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-2023
Mailing Address - Country:US
Mailing Address - Phone:716-680-2373
Mailing Address - Fax:
Practice Address - Street 1:2478 GEORGE URBAN BLVD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-2010
Practice Address - Country:US
Practice Address - Phone:716-680-2373
Practice Address - Fax:716-901-7407
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1019531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical