Provider Demographics
NPI:1821437500
Name:VAN CORNEWAL, DIANE MARGARET (LCSW LISAC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARGARET
Last Name:VAN CORNEWAL
Suffix:
Gender:F
Credentials:LCSW LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 N BEAVER ST
Mailing Address - Street 2:FLAGSTAFF MEDICAL CENTER
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3126
Mailing Address - Country:US
Mailing Address - Phone:928-213-6415
Mailing Address - Fax:928-213-6409
Practice Address - Street 1:1215 N BEAVER ST
Practice Address - Street 2:FLAGSTAFF MEDICAL CENTER
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-213-6415
Practice Address - Fax:928-213-6409
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10581101YA0400X
AZLCSW-10760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)