Provider Demographics
NPI:1912120346
Name:CORNWALL, VALERIE J (PT)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:J
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1140
Mailing Address - Country:US
Mailing Address - Phone:616-490-5903
Mailing Address - Fax:
Practice Address - Street 1:3400 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1854
Practice Address - Country:US
Practice Address - Phone:616-534-5487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
MI5501003995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
236598Medicare ID - Type Unspecified