Healthcare Provider Details

I. General information

NPI: 1477034056
Provider Name (Legal Business Name): CORNELLISS TAYLOR MSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 01/12/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD UNIT B
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

1271 WASHINGTON AVE 474 SAN LEANDRO, CA 94577
SAN LEANDRO CA
94577
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6666
  • Fax:
Mailing address:
  • Phone: 510-820-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW82059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: