MEDICARE: CASANDRA MINERVA CORREA CPS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	E2994994	CA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	R1580960924	CA

General Provider Information

NPI Number	:	1417780610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASANDRA MINERVA CORREA CPS

Provider Business Mailing Address
First Line	:	10717 CAMINO RUIZ STE 207
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-2364
Country	:	US
Telephone Number	:	858-695-2211
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 BIRMINGHAM DR STE 240A
Second Line	:
City	:	CARDIFF
State	:	CA
Zip	:	92007-1757
Country	:	US
Telephone Number	:	858-208-0121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	03/20/2026

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