Provider Demographics
NPI:1578586426
Name:CORNWELL, BRUCE WILLIAM (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WILLIAM
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 SE 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-5417
Mailing Address - Country:US
Mailing Address - Phone:352-226-5566
Mailing Address - Fax:
Practice Address - Street 1:1029 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3469
Practice Address - Country:US
Practice Address - Phone:352-376-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS200001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical