Healthcare Provider Details

I. General information

NPI: 1841712742
Provider Name (Legal Business Name): KIARA VALENI CORNEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date: 05/04/2021
Reactivation Date: 05/25/2021

III. Provider practice location address

1461 E COOLEY DR STE 100
COLTON CA
92324-3921
US

IV. Provider business mailing address

25910 ACERO STE 160
MISSION VIEJO CA
92691-2777
US

V. Phone/Fax

Practice location:
  • Phone: 909-835-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7167
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number129782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: