Provider Demographics
NPI:1386225811
Name:CORNWALL, BETINA MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:BETINA
Middle Name:MARIE
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 ARBUTUS ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-7102
Mailing Address - Country:US
Mailing Address - Phone:860-301-2621
Mailing Address - Fax:
Practice Address - Street 1:95 WOLF HARBOR RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-1938
Practice Address - Country:US
Practice Address - Phone:203-882-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1159103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst