Provider Demographics
NPI:1669017844
Name:CORNWELL, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:CORNWELL
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 1:741 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2201
Mailing Address - Country:US
Mailing Address - Phone:716-218-1400
Mailing Address - Fax:
Practice Address - Street 1:76 W HUMBOLDT PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2605
Practice Address - Country:US
Practice Address - Phone:716-835-9745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00009431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health