Provider Demographics
NPI:1598323545
Name:CORNISH, AUDREY IRENE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:IRENE
Last Name:CORNISH
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 1:911 E RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NE
Mailing Address - Zip Code:68418-4037
Mailing Address - Country:US
Mailing Address - Phone:402-405-1171
Mailing Address - Fax:
Practice Address - Street 1:1640 L ST STE C
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68508-2581
Practice Address - Country:US
Practice Address - Phone:402-489-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2170101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health