Provider Demographics
NPI:1144374729
Name:CORNEJO, KATYA (PSYD)
Entity type:Individual
Prefix:DR
First Name:KATYA
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-3515
Mailing Address - Country:US
Mailing Address - Phone:415-948-6992
Mailing Address - Fax:415-235-0995
Practice Address - Street 1:1833 FILLMORE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3180
Practice Address - Country:US
Practice Address - Phone:415-572-1126
Practice Address - Fax:415-931-3166
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA23822103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor