Provider Demographics
NPI:1689116162
Name:CORNWELL, REBECCA (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-2707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-2707
Practice Address - Country:US
Practice Address - Phone:334-277-4372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2017-090103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2017-090OtherALABAMA BEHAVIOR ANALYST LICENSURE BOARD
13999037OtherCAQH
1-14-15309OtherBEHAVIOR ANALYST CERTIFICATION BOARD