Provider Demographics
NPI:1669734687
Name:CORNELL, SHANNON NICOLE (MS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:CORNELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-1227
Mailing Address - Country:US
Mailing Address - Phone:856-889-1505
Mailing Address - Fax:
Practice Address - Street 1:483 FORDHAM RD
Practice Address - Street 2:
Practice Address - City:WENONAH
Practice Address - State:NJ
Practice Address - Zip Code:08090-1227
Practice Address - Country:US
Practice Address - Phone:856-889-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health