Provider Demographics
NPI:1801488937
Name:CORNWELL, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 RESEARCH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3268
Mailing Address - Country:US
Mailing Address - Phone:240-366-1191
Mailing Address - Fax:
Practice Address - Street 1:2275 RESEARCH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3268
Practice Address - Country:US
Practice Address - Phone:240-366-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health