Healthcare Provider Details

I. General information

NPI: 1417508904
Provider Name (Legal Business Name): SONYA L CORNWELL PHD CLINICAL PSYCHOLOGIST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W KEETOOWAH ST
TAHLEQUAH OK
74464-3824
US

IV. Provider business mailing address

310 W KEETOOWAH ST
TAHLEQUAH OK
74464-3824
US

V. Phone/Fax

Practice location:
  • Phone: 918-708-9558
  • Fax: 918-708-9580
Mailing address:
  • Phone: 918-708-9558
  • Fax: 918-708-9580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SONYA L CORNWELL
Title or Position: PHD AND OWNER
Credential: PHD
Phone: 918-708-9558