Provider Demographics
NPI:1326183195
Name:BUSSE, CORNELIA (LCSW)
Entity type:Individual
Prefix:
First Name:CORNELIA
Middle Name:
Last Name:BUSSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18860 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-4729
Mailing Address - Country:US
Mailing Address - Phone:707-578-8008
Mailing Address - Fax:
Practice Address - Street 1:2455 BENNETT VALLEY RD STE B208
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5667
Practice Address - Country:US
Practice Address - Phone:707-363-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS135381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical