Healthcare Provider Details

I. General information

NPI: 1851543623
Provider Name (Legal Business Name): BRETT DELESTER CORNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 YELLOWSTONE DR STE 110
CHICO CA
95973-5884
US

IV. Provider business mailing address

130 YELLOWSTONE DR STE 110
CHICO CA
95973-5884
US

V. Phone/Fax

Practice location:
  • Phone: 530-876-5991
  • Fax: 530-879-5990
Mailing address:
  • Phone: 530-879-5991
  • Fax: 530-879-5990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: