Provider Demographics
NPI:1730272618
Name:CORNWALL, CHARLES JR (MA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:CORNWALL
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:202 SECOND ST.
Mailing Address - City:ULSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18850-0104
Mailing Address - Country:US
Mailing Address - Phone:570-358-3905
Mailing Address - Fax:570-265-1075
Practice Address - Street 1:21 MAIN ST
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-1803
Practice Address - Country:US
Practice Address - Phone:570-265-2525
Practice Address - Fax:570-265-1075
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002239L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist