Provider Demographics
NPI:1669570198
Name:CORNELL, CYNTHIA ANN (OTR L)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ANN
Last Name:CORNELL
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:FLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:500 CLIFTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907
Mailing Address - Country:US
Mailing Address - Phone:419-756-5375
Mailing Address - Fax:
Practice Address - Street 1:270 STERKEL BLVD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2207
Practice Address - Country:US
Practice Address - Phone:419-756-1133
Practice Address - Fax:419-756-6544
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OT 02865225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3407897499238OtherANTHEM
000000125368OtherANTHEM