Provider Demographics
NPI:1619488657
Name:CORNEJO, MARTHA IMELDA (MFTI)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:IMELDA
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SUMMERTIME LN
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-1305
Mailing Address - Country:US
Mailing Address - Phone:707-290-2782
Mailing Address - Fax:
Practice Address - Street 1:1255 ALLSTON WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1833
Practice Address - Country:US
Practice Address - Phone:510-845-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician