Provider Demographics
NPI:1396280087
Name:KORNGUT, HERSHEL
Entity type:Individual
Prefix:
First Name:HERSHEL
Middle Name:
Last Name:KORNGUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4859 COLDWATER CANYON AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-2235
Mailing Address - Country:US
Mailing Address - Phone:626-528-2587
Mailing Address - Fax:
Practice Address - Street 1:4859 COLDWATER CANYON AVE APT 15
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-2235
Practice Address - Country:US
Practice Address - Phone:626-528-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2024-05-30
Deactivation Date:2022-04-28
Deactivation Code:
Reactivation Date:2022-05-27
Provider Licenses
StateLicense IDTaxonomies
CAR1539061223101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)