Provider Demographics
NPI:1659483741
Name:CORNISH, KATHLEEN ROSE (MSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:CORNISH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536
Mailing Address - Country:US
Mailing Address - Phone:843-774-3351
Mailing Address - Fax:843-774-2622
Practice Address - Street 1:1324 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536
Practice Address - Country:US
Practice Address - Phone:843-774-3351
Practice Address - Fax:843-774-2622
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC405127Medicaid