Provider Demographics
NPI:1184492415
Name:CORNEJO, KLARYSSA YOLANDA
Entity type:Individual
Prefix:
First Name:KLARYSSA
Middle Name:YOLANDA
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 1:13550 S ROUTE 30 STE 204E
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-5688
Mailing Address - Country:US
Mailing Address - Phone:815-308-2322
Mailing Address - Fax:844-991-3532
Practice Address - Street 1:13550 S ROUTE 30 STE 204E
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-5688
Practice Address - Country:US
Practice Address - Phone:815-308-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst