Provider Demographics
NPI:1588334791
Name:KORNBLATT, LOUISA MIRIAM (LCSW)
Entity type:Individual
Prefix:
First Name:LOUISA
Middle Name:MIRIAM
Last Name:KORNBLATT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LEXINGTON AVE APT 4C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-6318
Mailing Address - Country:US
Mailing Address - Phone:608-770-1868
Mailing Address - Fax:
Practice Address - Street 1:5201 GREAT AMERICA PKWY STE 320
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-1140
Practice Address - Country:US
Practice Address - Phone:323-205-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1107361041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical