Provider Demographics
NPI:1467889253
Name:CORNELL, MELISSA JUNE MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JUNE MARIE
Last Name:CORNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JUNE MARIE
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:160 SUSIE CT
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 SW LEE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3823
Practice Address - Country:US
Practice Address - Phone:541-574-5960
Practice Address - Fax:844-760-0526
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator