Healthcare Provider Details

I. General information

NPI: 1194216374
Provider Name (Legal Business Name): SONYA LYNN CORNWELL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SONYA LYNN GIFFORD-CORNWELL PH.D.

II. Dates (important events)

Enumeration Date: 05/23/2018
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: 817-307-0949
  • Fax:
Mailing address:
  • Phone: 918-708-9558
  • Fax: 918-708-9580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1309
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1309
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1309
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1309
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1309
License Number StateOK

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: