Provider Demographics
NPI:1699796011
Name:CORNIDE, CARMEN ROSA (PSY D)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:ROSA
Last Name:CORNIDE
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N PALM AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3200
Mailing Address - Country:US
Mailing Address - Phone:954-443-0018
Mailing Address - Fax:954-432-3470
Practice Address - Street 1:1601 N PALM AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3200
Practice Address - Country:US
Practice Address - Phone:954-443-0018
Practice Address - Fax:954-432-3470
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5595103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54131BMedicare ID - Type Unspecified
FL54131Medicare ID - Type Unspecified