Provider Demographics
NPI:1639611569
Name:CORENBLUM, CARL (MSW,LSW)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:CORENBLUM
Suffix:
Gender:M
Credentials:MSW,LSW
Other - Prefix:
Other - First Name:EITAN
Other - Middle Name:
Other - Last Name:CORENBLUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:921 E NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 E NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1309
Practice Address - Country:US
Practice Address - Phone:718-778-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYKC81202GMedicaid