Provider Demographics
NPI:1356636849
Name:CORNACCHIONE, NICOLE JORENE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JORENE
Last Name:CORNACCHIONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JORENE
Other - Last Name:LOWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:23208 ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3514
Mailing Address - Country:US
Mailing Address - Phone:810-610-8037
Mailing Address - Fax:
Practice Address - Street 1:23208 ASHLEY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-3514
Practice Address - Country:US
Practice Address - Phone:810-610-8037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010889301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical