Provider Demographics
NPI:1922176551
Name:CORNISH, KIM ANN (PHD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANN
Last Name:CORNISH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8698 ELK GROVE BLVD.,
Mailing Address - Street 2:SUITE 1, PMB 170
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624
Mailing Address - Country:US
Mailing Address - Phone:530-514-1066
Mailing Address - Fax:916-687-3140
Practice Address - Street 1:8788 ELK GROVE BLVD.
Practice Address - Street 2:BLDG. 2, STE F
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624
Practice Address - Country:US
Practice Address - Phone:530-514-1066
Practice Address - Fax:916-687-3140
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18648103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical