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NPI Code Detail

MEDICARE: KRISTOPHER LEE CORNWELL BA/LSW

MEDICARE: KRISTOPHER LEE CORNWELL BA/LSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial WorkerS0600813OH

General Provider Information

NPI Number : 1306190079
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTOPHER LEE CORNWELL BA/LSW
Provider Business Mailing Address
First Line : 2745 S SMITHVILLE RD
Second Line :
City : DAYTON
State : OH
Zip : 45420-2668
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2745 S SMITHVILLE RD
Second Line :
City : DAYTON
State : OH
Zip : 45420-2668
Country : US
Telephone Number : 937-258-4233
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/02/2012
Last Update Date : 11/02/2012

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