Provider Demographics
NPI:1346465580
Name:CORNELL, CATHERINE IVES (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:IVES
Last Name:CORNELL
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592A WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-6417
Mailing Address - Country:US
Mailing Address - Phone:781-239-3368
Mailing Address - Fax:
Practice Address - Street 1:592A WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-6417
Practice Address - Country:US
Practice Address - Phone:781-239-3368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1050231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3135OtherBLUE CROSS BLUE SHIELD
MACO P20996Medicare ID - Type UnspecifiedMEDICARE