Provider Demographics
NPI:1316069180
Name:CORNEJO, SANDRA SUZANNA
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:SUZANNA
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 1:68625 PEREZ RD STE 11A
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7250
Mailing Address - Country:US
Mailing Address - Phone:760-773-6767
Mailing Address - Fax:760-773-6760
Practice Address - Street 1:68625 PEREZ RD STE 11A
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7250
Practice Address - Country:US
Practice Address - Phone:760-773-6767
Practice Address - Fax:760-773-6760
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACALPU1-224-101111S101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)