Provider Demographics
NPI:1891142584
Name:CORNEJO, ORTA
Entity Type:Individual
Prefix:
First Name:ORTA
Middle Name:
Last Name:CORNEJO
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 1:16242 SW 304TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-4137
Mailing Address - Country:US
Mailing Address - Phone:786-259-3036
Mailing Address - Fax:
Practice Address - Street 1:14335 SW 120TH ST
Practice Address - Street 2:201
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7294
Practice Address - Country:US
Practice Address - Phone:305-967-8074
Practice Address - Fax:305-967-8302
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-08840106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician