Provider Demographics
NPI:1710456504
Name:KORNIEJ, STEPHEN ANDREW
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANDREW
Last Name:KORNIEJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GOUGH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5903
Mailing Address - Country:US
Mailing Address - Phone:415-553-3252
Mailing Address - Fax:
Practice Address - Street 1:101 GOUGH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-5903
Practice Address - Country:US
Practice Address - Phone:415-553-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)