Healthcare Provider Details

I. General information

NPI: 1033666979
Provider Name (Legal Business Name): PAMELA A CORNEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

777 BANNOCK ST
DENVER CO
80204-4597
US

V. Phone/Fax

Practice location:
  • Phone: 303-436-4949
  • Fax: 303-602-0050
Mailing address:
  • Phone: 303-436-4949
  • Fax: 303-602-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0006480
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: