Provider Demographics
NPI:1417780610
Name:CORREA, CASANDRA MINERVA (CPS)
Entity type:Individual
Prefix:
First Name:CASANDRA
Middle Name:MINERVA
Last Name:CORREA
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10717 CAMINO RUIZ STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2364
Mailing Address - Country:US
Mailing Address - Phone:858-695-2211
Mailing Address - Fax:
Practice Address - Street 1:10717 CAMINO RUIZ STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2364
Practice Address - Country:US
Practice Address - Phone:858-695-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2994994175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist