Provider Demographics
NPI:1881744670
Name:CORNELLIER, VINCENT (PHD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:CORNELLIER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3580
Mailing Address - Country:US
Mailing Address - Phone:231-935-8540
Mailing Address - Fax:231-935-8544
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-8540
Practice Address - Fax:231-935-8544
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002081103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVC002081OtherBLUE CROSS
MIVC002081OtherBLUE CROSS