Healthcare Provider Details

I. General information

NPI: 1760747265
Provider Name (Legal Business Name): REBECCA KORNBLUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

IV. Provider business mailing address

4440 UNIVERSITY AVE
RIVERSIDE CA
92501-3199
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 866-218-4697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 78133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: