Provider Demographics
NPI:1639343197
Name:KORNBERG WISEMAN, RENA (OT)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:KORNBERG WISEMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 RESERVOIR RD
Mailing Address - Street 2:
Mailing Address - City:N WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2522
Mailing Address - Country:US
Mailing Address - Phone:914-948-7190
Mailing Address - Fax:914-948-7491
Practice Address - Street 1:7 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:N WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-2522
Practice Address - Country:US
Practice Address - Phone:914-948-7190
Practice Address - Fax:914-948-7491
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6213459225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand