Provider Demographics
NPI:1700367224
Name:CORNELIUS, TIA (COTA)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 KECK RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3564
Mailing Address - Country:US
Mailing Address - Phone:630-336-6216
Mailing Address - Fax:
Practice Address - Street 1:1601 PRECISION PARK LN
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-1345
Practice Address - Country:US
Practice Address - Phone:619-205-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4979224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant