Provider Demographics
NPI:1942416912
Name:KORNBAU, KYLE M (LCMHC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:M
Last Name:KORNBAU
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PEMBERTON HILL RD #103
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-3957
Mailing Address - Country:US
Mailing Address - Phone:919-434-6398
Mailing Address - Fax:919-557-2089
Practice Address - Street 1:1101 PEMBERTON HILL RD STE 103
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3957
Practice Address - Country:US
Practice Address - Phone:919-434-6398
Practice Address - Fax:919-557-2089
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7714101YM0800X
NC3335103TC1900X
NCS7714101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling