Provider Demographics
NPI:1679982375
Name:KORNUSZKO, EDWARD VINCENT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:VINCENT
Last Name:KORNUSZKO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 ELLISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8008
Mailing Address - Country:US
Mailing Address - Phone:781-835-5664
Mailing Address - Fax:
Practice Address - Street 1:137 ELLISON AVE
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8008
Practice Address - Country:US
Practice Address - Phone:781-835-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9078103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical