MEDICARE: KATHLEYN CARR KORNHEISL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0704017108	VA

General Provider Information

NPI Number	:	1528569084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEYN CARR KORNHEISL

Provider Business Mailing Address
First Line	:	1030 LOFTIS BLVD STE 102
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-2999
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1030 LOFTIS BLVD STE 102
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-2999
Country	:	US
Telephone Number	:	978-998-5022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2018
Last Update Date	:	12/03/2024

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