Provider Demographics
NPI:1508455767
Name:CORNELIUS, KENYATTE
Entity Type:Individual
Prefix:
First Name:KENYATTE
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6955 FOOTHILL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2421
Mailing Address - Country:US
Mailing Address - Phone:510-703-8864
Mailing Address - Fax:
Practice Address - Street 1:6955 FOOTHILL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2421
Practice Address - Country:US
Practice Address - Phone:510-703-8864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF97132106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist