Provider Demographics
NPI:1770624173
Name:CORNELL, MARCIA (MA, CCC-A)
Entity type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:
Last Name:CORNELL
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 WEST ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3502
Mailing Address - Country:US
Mailing Address - Phone:860-567-3133
Mailing Address - Fax:860-567-8346
Practice Address - Street 1:63 WEST ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3502
Practice Address - Country:US
Practice Address - Phone:860-567-3133
Practice Address - Fax:860-567-8346
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000013237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTR39072Medicare UPIN
640000030Medicare ID - Type Unspecified