Provider Demographics
NPI:1043827702
Name:CORNWALL, AMY CONSTANCE JEAN (MA, LBS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:CONSTANCE JEAN
Last Name:CORNWALL
Suffix:
Gender:F
Credentials:MA, LBS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:C
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 N PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3010
Mailing Address - Country:US
Mailing Address - Phone:717-560-7917
Mailing Address - Fax:717-560-6452
Practice Address - Street 1:410 N PRINCE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-3010
Practice Address - Country:US
Practice Address - Phone:717-560-7917
Practice Address - Fax:717-560-6452
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005095103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst