Provider Demographics
NPI:1568076974
Name:CORNELL, CLANCEY JO
Entity Type:Individual
Prefix:
First Name:CLANCEY
Middle Name:JO
Last Name:CORNELL
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 1:10736 JEFFERSON BLVD # 174
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4933
Mailing Address - Country:US
Mailing Address - Phone:310-980-2411
Mailing Address - Fax:
Practice Address - Street 1:923 S CATALINA AVE UNIT B
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-4718
Practice Address - Country:US
Practice Address - Phone:310-980-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program