Healthcare Provider Details

I. General information

NPI: 1497352405
Provider Name (Legal Business Name): CORNERSTONE MARRIAGE AND FAMILY THERAPY CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54425 N CIRCLE DRIVE SUITE 9 AND 10
IDYLLWILD CA
92549-9254
US

IV. Provider business mailing address

PO BOX 3519
IDYLLWILD CA
92549-3519
US

V. Phone/Fax

Practice location:
  • Phone: 760-207-7486
  • Fax:
Mailing address:
  • Phone: 760-207-7486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CARA WILKERSON
Title or Position: CEO/PRESIDENT/CLINICAL SUPERVISOR
Credential: MA, LMFT
Phone: 760-207-7486