Provider Demographics
NPI:1902090855
Name:CORNELIUS, BRIAN M
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 LINDA VISTA RD
Mailing Address - Street 2:APT. A2
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3142 VISTA WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3619
Practice Address - Country:US
Practice Address - Phone:760-758-1480
Practice Address - Fax:760-435-9472
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health