Provider Demographics
NPI:1811504723
Name:KORNBLUM, MORGAN TYLER (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:TYLER
Last Name:KORNBLUM
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:KY
Mailing Address - Zip Code:41073-1506
Mailing Address - Country:US
Mailing Address - Phone:859-663-6868
Mailing Address - Fax:
Practice Address - Street 1:2716 ERIE AVE STE B3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45208-2135
Practice Address - Country:US
Practice Address - Phone:513-208-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT018916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist