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General NPI Number Information
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NPI Number | 1477034056
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Entity Type | Individual
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Provider Name | CORNELLISS TAYLOR MSW, ACSW
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Gender | Female
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Dates
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Enumeration Date | 08/22/2018
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Last Update Date | 01/12/2022
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Provider Practice Location Address
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Address Line | 250 BON AIR RD UNIT B
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City | GREENBRAE
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State | CA
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Zip | 94904-1702
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Country | US
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Telephone | 415-473-6666
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Fax |
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Provider Business Mailing Address
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Address Line | 1271 WASHINGTON AVE 474 SAN LEANDRO, CA 94577
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City | SAN LEANDRO
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State | CA
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Zip | 94577
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Country | US
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Telephone | 510-820-5300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ASW82059
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License Number State | CA
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