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General NPI Number Information
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NPI Number | 1164973707
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Entity Type | Individual
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Provider Name | COURTNEY RACQUEL CORNICK PH.D.
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Gender | Female
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Dates
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Enumeration Date | 10/19/2016
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Last Update Date | 10/19/2016
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Provider Practice Location Address
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Address Line | 5000 S 5TH AVE HINES VA HOSPITAL/ BLDG 128 RM A114
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City | HINES
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State | IL
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Zip | 60141-3030
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Country | US
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Telephone | 708-202-8387
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Fax |
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Provider Business Mailing Address
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Address Line | 664 LAKEWOOD FARMS DR
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City | BOLINGBROOK
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State | IL
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Zip | 60490-3164
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Country | US
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Telephone | 630-310-9472
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3422-57
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License Number State | WI
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