Provider Demographics
NPI:1093487571
Name:KORNICK, MARY RIKER (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RIKER
Last Name:KORNICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-1424
Mailing Address - Country:US
Mailing Address - Phone:973-668-2604
Mailing Address - Fax:
Practice Address - Street 1:25 LINDSLEY DR STE 203
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-4456
Practice Address - Country:US
Practice Address - Phone:973-668-2604
Practice Address - Fax:973-998-7910
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00603600101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health