Provider Demographics
NPI:1134335763
Name:CORNWELL, CONNIE SUE (MA, LPC, LMFT)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:SUE
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:MA, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 VALLEYCREST LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-1602
Mailing Address - Country:US
Mailing Address - Phone:214-648-6949
Mailing Address - Fax:214-648-6946
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9121
Practice Address - Country:US
Practice Address - Phone:214-648-6849
Practice Address - Fax:214-648-6846
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2198101YP2500X
TX1887106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist