Provider Demographics
NPI:1760747265
Name:KORNBLUTH, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:KORNBLUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3199
Mailing Address - Country:US
Mailing Address - Phone:866-218-4697
Mailing Address - Fax:
Practice Address - Street 1:5870 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2037
Practice Address - Country:US
Practice Address - Phone:951-683-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 78133106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist