Provider Demographics
NPI:1164843959
Name:CORNWELL RAY, CARRIE (LCSW)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CORNWELL RAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N 47TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66102-1705
Mailing Address - Country:US
Mailing Address - Phone:913-287-0007
Mailing Address - Fax:913-233-3375
Practice Address - Street 1:6302 N WYANDOTTE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-3842
Practice Address - Country:US
Practice Address - Phone:816-332-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013038573104100000X
KS9039104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098080COtherSED WIAVER
KS100098080AMedicaid
KS100098080COtherSED WIAVER