Provider Demographics
NPI:1518745363
Name:CORNELISON-FORSYTHE, BRIGET MARIE
Entity Type:Individual
Prefix:
First Name:BRIGET
Middle Name:MARIE
Last Name:CORNELISON-FORSYTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 MECHANICSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-3147
Mailing Address - Country:US
Mailing Address - Phone:937-399-6101
Mailing Address - Fax:937-399-6609
Practice Address - Street 1:1918 MECHANICSBURG RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-3147
Practice Address - Country:US
Practice Address - Phone:937-399-6101
Practice Address - Fax:937-399-6609
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS9480104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker