Provider Demographics
NPI:1417508904
Name:SONYA L CORNWELL PHD CLINICAL PSYCHOLOGIST PLLC
Entity Type:Organization
Organization Name:SONYA L CORNWELL PHD CLINICAL PSYCHOLOGIST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORNWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-708-9558
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:918-708-9558
Practice Address - Fax:918-708-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty