Provider Demographics
NPI:1003411364
Name:KORNBLUM, MELANIE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:KORNBLUM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 CHRISTINA DR
Mailing Address - Street 2:
Mailing Address - City:PEVELY
Mailing Address - State:MO
Mailing Address - Zip Code:63070-1645
Mailing Address - Country:US
Mailing Address - Phone:314-769-2659
Mailing Address - Fax:
Practice Address - Street 1:1 MERAMEC BLUFFS DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-3309
Practice Address - Country:US
Practice Address - Phone:636-861-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014001334225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist