Provider Demographics
NPI:1073110086
Name:CORNELIUS, KEVIN (MA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 SOLACE PL STE D2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4337
Mailing Address - Country:US
Mailing Address - Phone:650-206-9049
Mailing Address - Fax:
Practice Address - Street 1:2660 SOLACE PL STE D2
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4337
Practice Address - Country:US
Practice Address - Phone:650-206-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122258106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist