Provider Demographics
NPI:1407187883
Name:CORNFORTH, MINDI (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MINDI
Middle Name:
Last Name:CORNFORTH
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W MAIN ST
Mailing Address - Street 2:PO BOX 662
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-4220
Mailing Address - Country:US
Mailing Address - Phone:405-527-1785
Mailing Address - Fax:405-527-1084
Practice Address - Street 1:112 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-4220
Practice Address - Country:US
Practice Address - Phone:405-527-1785
Practice Address - Fax:405-527-1084
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK05037101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional