Provider Demographics
NPI:1821612490
Name:CORNWALL, SEAN M
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:CORNWALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 HELENA RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-4130
Mailing Address - Country:US
Mailing Address - Phone:717-823-7674
Mailing Address - Fax:
Practice Address - Street 1:313 W LIBERTY ST STE 226C
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2791
Practice Address - Country:US
Practice Address - Phone:717-723-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-30
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAMF001493106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104121034-0004Medicaid