Provider Demographics
NPI:1992177133
Name:KORNBLUH, LEAH (MS BCBA)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:KORNBLUH
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 COLONY CIR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1403
Mailing Address - Country:US
Mailing Address - Phone:917-757-0022
Mailing Address - Fax:
Practice Address - Street 1:40 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5894
Practice Address - Country:US
Practice Address - Phone:732-833-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-15-19606103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst