Basic Information
| Provider Information | |||||||||
| NPI: | 1356888234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORNELUS | ||||||||
| FirstName: | NED | ||||||||
| MiddleName: | WALTER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 N JOHNSON AVE | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920201650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194411493 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2049 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | LEMON GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194657303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2017 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.