Provider Demographics
NPI:1073684841
Name:KORN, ERIC (PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 MAIN ST
Mailing Address - Street 2:P O BOX 113
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-2600
Mailing Address - Country:US
Mailing Address - Phone:508-478-6725
Mailing Address - Fax:508-634-7065
Practice Address - Street 1:89 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2600
Practice Address - Country:US
Practice Address - Phone:508-478-6725
Practice Address - Fax:508-634-7065
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2307103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02472Medicare ID - Type Unspecified