Provider Demographics
NPI:1811624448
Name:CORNELIO, STEPHANIE
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:CORNELIO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:RIVERA-FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18726 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:201 N BRAND BLVD
Practice Address - Street 2:OFFICE #233
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-722-1770
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician