Provider Demographics
NPI:1528539186
Name:CORNELY, FRITZ
Entity Type:Individual
Prefix:MR
First Name:FRITZ
Middle Name:
Last Name:CORNELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 JEAN AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-6325
Mailing Address - Country:US
Mailing Address - Phone:516-833-7219
Mailing Address - Fax:
Practice Address - Street 1:92 JEAN AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-6325
Practice Address - Country:US
Practice Address - Phone:516-833-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1056935161103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst