Provider Demographics
NPI:1477700367
Name:CORNWELL, SHANNON (MA, LMT, LMP)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:MA, LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6761
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-8933
Mailing Address - Country:US
Mailing Address - Phone:808-557-5433
Mailing Address - Fax:
Practice Address - Street 1:1028 KINOOLE ST STE 103
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3800
Practice Address - Country:US
Practice Address - Phone:808-557-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 9172172M00000X
WAMA 00021877172M00000X
HIMHC 281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172M00000XOther Service ProvidersMechanotherapist