Provider Demographics
NPI:1457644452
Name:KORNBLUTH, LESLIE (LICSW)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:KORNBLUTH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 RANDALL CT
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-4422
Mailing Address - Country:US
Mailing Address - Phone:504-352-5094
Mailing Address - Fax:
Practice Address - Street 1:2 RANDALL CT
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-4422
Practice Address - Country:US
Practice Address - Phone:504-352-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1186081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical