=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548697972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEILAN COOK-CORNMAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2013
-----------------------------------------------------
Last Update Date | 01/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 W MAIN ST
-----------------------------------------------------
City | SULLIVAN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63080-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-205-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16060 COUNTY ROAD 1050
-----------------------------------------------------
City | SAINT JAMES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65559-8679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-205-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------