Provider Demographics
NPI:1356155717
Name:CORNEJO, RODESSA MERYLL MAE
Entity type:Individual
Prefix:
First Name:RODESSA MERYLL MAE
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6238 COMMONWEALTH DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-8638
Mailing Address - Country:US
Mailing Address - Phone:815-721-6852
Mailing Address - Fax:
Practice Address - Street 1:6238 COMMONWEALTH DR
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-8638
Practice Address - Country:US
Practice Address - Phone:815-721-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.115026104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker