Provider Demographics
NPI:1215331772
Name:KORNBLUM, MONICA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:KORNBLUM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CLEAR LAKE CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-2501
Mailing Address - Country:US
Mailing Address - Phone:405-537-4471
Mailing Address - Fax:
Practice Address - Street 1:3100 CLEAR LAKE CT
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-2501
Practice Address - Country:US
Practice Address - Phone:405-537-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist