Provider Demographics
NPI:1477034056
Name:TAYLOR, CORNELLISS (MSW, ACSW)
Entity Type:Individual
Prefix:
First Name:CORNELLISS
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 WASHINGTON AVE 474
Mailing Address - Street 2:SAN LEANDRO, CA 94577
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577
Mailing Address - Country:US
Mailing Address - Phone:510-820-5300
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR RD UNIT B
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-473-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW82059101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health