Provider Demographics
NPI:1174710669
Name:KORNBLATT, REBECCA S (PSYD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:S
Last Name:KORNBLATT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LANGLEY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1972
Mailing Address - Country:US
Mailing Address - Phone:617-615-6525
Mailing Address - Fax:
Practice Address - Street 1:10 LANGLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-1972
Practice Address - Country:US
Practice Address - Phone:617-615-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017233-1103TC0700X
MA9176103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0015725OtherMEDICARE PTAN
NYV50501Medicare PIN