Healthcare Provider Details

I. General information

NPI: 1992290449
Provider Name (Legal Business Name): KAITLYN CORNELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820
US

IV. Provider business mailing address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax:
Mailing address:
  • Phone: 217-356-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: