Healthcare Provider Details

I. General information

NPI: 1114198769
Provider Name (Legal Business Name): MELISSA ANN CORNISH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6208 CROOKED CREEK DRIVE
MASON OH
45040
US

IV. Provider business mailing address

6208 CROOKED CREEK DR
MASON OH
45040-2444
US

V. Phone/Fax

Practice location:
  • Phone: 937-901-6267
  • Fax: 866-481-8354
Mailing address:
  • Phone: 937-901-6267
  • Fax: 866-481-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: