Healthcare Provider Details

I. General information

NPI: 1710569165
Provider Name (Legal Business Name): COURTNEY MAE CORNELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 S CENTRAL AVE
MARSHFIELD WI
54449-4917
US

IV. Provider business mailing address

5814 11TH AVE
KENOSHA WI
53140-4016
US

V. Phone/Fax

Practice location:
  • Phone: 262-997-9411
  • Fax:
Mailing address:
  • Phone: 608-571-2931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10152-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: