Provider Demographics
NPI:1295097095
Name:CORNETT, TANYA L (CDCA)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:CORNETT
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:L
Other - Last Name:CORNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC-S
Mailing Address - Street 1:1020 SYMMES ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014
Mailing Address - Country:US
Mailing Address - Phone:513-868-7654
Mailing Address - Fax:513-883-1546
Practice Address - Street 1:294 N FAIR AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011
Practice Address - Country:US
Practice Address - Phone:513-868-7654
Practice Address - Fax:513-883-1546
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1100052-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0206693Medicaid