Provider Demographics
NPI:1427866979
Name:KORSAH, TONYA DENISE
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:DENISE
Last Name:KORSAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18-20 LACKAWANNA PLZ
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3642
Mailing Address - Country:US
Mailing Address - Phone:973-969-1081
Mailing Address - Fax:
Practice Address - Street 1:18-20 LACKAWANNA PLZ
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3642
Practice Address - Country:US
Practice Address - Phone:973-969-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities