Healthcare Provider Details

I. General information

NPI: 1902090855
Provider Name (Legal Business Name): BRIAN M CORNELIUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 VISTA WAY SUITE 205
OCEANSIDE CA
92056-3619
US

IV. Provider business mailing address

6620 LINDA VISTA RD APT. A2
SAN DIEGO CA
92111-7367
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-1480
  • Fax: 760-435-9472
Mailing address:
  • Phone:
  • Fax:

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: