Provider Demographics
NPI:1225748569
Name:EDWARD V KORNUSZKO PSY D PA
Entity Type:Organization
Organization Name:EDWARD V KORNUSZKO PSY D PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNUSZKO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:781-835-5664
Mailing Address - Street 1:7056 LANIER FALLS RD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-0007
Mailing Address - Country:US
Mailing Address - Phone:781-835-5664
Mailing Address - Fax:
Practice Address - Street 1:7056 LANIER FALLS RD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-0007
Practice Address - Country:US
Practice Address - Phone:781-835-5664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty