Provider Demographics
NPI:1356494769
Name:CORNELIUS, RICHARD (SUDCC II)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:SUDCC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E VANDERBILT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-388-0801
Mailing Address - Fax:909-501-0832
Practice Address - Street 1:658 E BRIER DR STE 350
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2875
Practice Address - Country:US
Practice Address - Phone:800-968-2636
Practice Address - Fax:909-501-0832
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13154101YA0400X, 101YA0400X
CAAII053920418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty