Healthcare Provider Details

I. General information

NPI: 1992177133
Provider Name (Legal Business Name): LEAH KORNBLUH MS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CHESTNUT ST
LAKEWOOD NJ
08701-5894
US

IV. Provider business mailing address

121 COLONY CIR
LAKEWOOD NJ
08701-1403
US

V. Phone/Fax

Practice location:
  • Phone: 732-833-3723
  • Fax:
Mailing address:
  • Phone: 917-757-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-15-19606
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: