Healthcare Provider Details

I. General information

NPI: 1740197714
Provider Name (Legal Business Name): RAUL ERNESTO CORNEJO ACSW 138733
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35325 DATE PALM DR STE 150
CATHEDRAL CITY CA
92234-7002
US

IV. Provider business mailing address

15102 RIVERVIEW LN
VICTORVILLE CA
92394-0547
US

V. Phone/Fax

Practice location:
  • Phone: 442-307-3395
  • Fax:
Mailing address:
  • Phone: 551-208-5629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: