Provider Demographics
NPI:1013080571
Name:CORNELL, MARILYN PATRICIA (MS, MFT)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:PATRICIA
Last Name:CORNELL
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3019
Mailing Address - Country:US
Mailing Address - Phone:619-293-0634
Mailing Address - Fax:619-294-3225
Practice Address - Street 1:3821 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3019
Practice Address - Country:US
Practice Address - Phone:619-293-0634
Practice Address - Fax:619-294-3225
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28342106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT283420OtherBLUE SHIELD OF CALIFORNIA