Provider Demographics
NPI:1972291151
Name:KORNEGAY, PHILIP DOUGLAS (LMFT)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:DOUGLAS
Last Name:KORNEGAY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11115 OAK BEND CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-4848
Mailing Address - Country:US
Mailing Address - Phone:502-377-5954
Mailing Address - Fax:
Practice Address - Street 1:4229 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3241
Practice Address - Country:US
Practice Address - Phone:502-465-8687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY280884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist