Healthcare Provider Details

I. General information

NPI: 1720219561
Provider Name (Legal Business Name): ROBERT BRUCE CORNELL MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 SINALOA AVE
PASADENA CA
91104-3152
US

IV. Provider business mailing address

1211 SINALOA AVE
PASADENA CA
91104-3152
US

V. Phone/Fax

Practice location:
  • Phone: 626-991-1080
  • Fax:
Mailing address:
  • Phone: 626-398-5581
  • Fax: 626-398-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number42969
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number42969
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: