Provider Demographics
NPI:1194216374
Name:CORNWELL, SONYA LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SONYA
Middle Name:LYNN
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SONYA
Other - Middle Name:LYNN
Other - Last Name:GIFFORD-CORNWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:310 W KEETOOWAH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3824
Mailing Address - Country:US
Mailing Address - Phone:918-708-9558
Mailing Address - Fax:918-708-9580
Practice Address - Street 1:310 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3824
Practice Address - Country:US
Practice Address - Phone:817-307-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1309103TA0700X, 103TB0200X, 103TC2200X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service