Healthcare Provider Details

I. General information

NPI: 1821612490
Provider Name (Legal Business Name): SEAN M CORNWALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2020
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W LIBERTY ST STE 226C
LANCASTER PA
17603-2791
US

IV. Provider business mailing address

2502 HELENA RD
LANCASTER PA
17603-4130
US

V. Phone/Fax

Practice location:
  • Phone: 717-723-9729
  • Fax:
Mailing address:
  • Phone: 717-823-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMF001493
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMF001493
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: