Provider Demographics
NPI:1669042594
Name:CORNWALL, MARIAH
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:CORNWALL
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 1:157 S HOWARD ST STE 310
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-4421
Mailing Address - Country:US
Mailing Address - Phone:800-781-5536
Mailing Address - Fax:
Practice Address - Street 1:157 S HOWARD ST STE 310
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4421
Practice Address - Country:US
Practice Address - Phone:800-781-5536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician