Provider Demographics
NPI:1609185503
Name:CORNISH, RICHARD GORDON (LPC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GORDON
Last Name:CORNISH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E CHOCTAW AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5098
Mailing Address - Country:US
Mailing Address - Phone:918-420-5006
Mailing Address - Fax:
Practice Address - Street 1:23 E CHOCTAW AVE STE 3
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5098
Practice Address - Country:US
Practice Address - Phone:918-420-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional