Provider Demographics
NPI:1285217547
Name:CORNELL-MULLANE, KAITLYNN B (LCAT, RDT, MA)
Entity Type:Individual
Prefix:
First Name:KAITLYNN
Middle Name:B
Last Name:CORNELL-MULLANE
Suffix:
Gender:F
Credentials:LCAT, RDT, MA
Other - Prefix:
Other - First Name:KAITLYNN
Other - Middle Name:B
Other - Last Name:CORNELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:802 SENECA AVE APT 3L
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4810
Mailing Address - Country:US
Mailing Address - Phone:845-901-2799
Mailing Address - Fax:
Practice Address - Street 1:802 SENECA AVE APT 3L
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4810
Practice Address - Country:US
Practice Address - Phone:845-901-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002579101200000X, 221700000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist