Provider Demographics
NPI:1629709738
Name:CORNEJO, ELIZA LEE
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:LEE
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:N17025 DALE VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:GALESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54630-8723
Mailing Address - Country:US
Mailing Address - Phone:608-792-2329
Mailing Address - Fax:
Practice Address - Street 1:605 4TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4458
Practice Address - Country:US
Practice Address - Phone:608-622-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12780104100000X
WI132936-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker