Provider Demographics
NPI:1699531731
Name:MICHAEL CORNWALL PHD LLC
Entity type:Organization
Organization Name:MICHAEL CORNWALL PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNWALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-321-4956
Mailing Address - Street 1:7115 PICO RIO CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-7154
Mailing Address - Country:US
Mailing Address - Phone:859-321-4956
Mailing Address - Fax:
Practice Address - Street 1:2110 E FLAMINGO RD STE 207
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5191
Practice Address - Country:US
Practice Address - Phone:859-321-4956
Practice Address - Fax:702-472-8635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty