Basic Information
| Provider Information | |||||||||
| NPI: | 1487165023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORBELAK | ||||||||
| FirstName: | CHRISTIANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| OtherLastName: | GROSSO | ||||||||
| OtherFirstName: | CHRISTIANA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6914 HOLABIRD AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212221747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102845441 | ||||||||
| FaxNumber: | 4102845442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 YORK RD STE 19 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102969195 | ||||||||
| FaxNumber: | 4102969197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 10/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 26710 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.