Provider Demographics
NPI:1720561202
Name:KORNBLUH, NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KORNBLUH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 ANNABRANCH TRCE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-5755
Mailing Address - Country:US
Mailing Address - Phone:757-284-1938
Mailing Address - Fax:
Practice Address - Street 1:1010 ANNABRANCH TRCE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-5755
Practice Address - Country:US
Practice Address - Phone:757-284-1938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015720101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor