Provider Demographics
NPI:1013742063
Name:KORNBLAU, MARISSA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:
Last Name:KORNBLAU
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-4504
Mailing Address - Country:US
Mailing Address - Phone:917-208-0426
Mailing Address - Fax:
Practice Address - Street 1:55 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-4504
Practice Address - Country:US
Practice Address - Phone:917-208-0426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1187301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical