Provider Demographics
NPI:1033997549
Name:PRICE, KOURTNEY R (MA, LLC)
Entity Type:Individual
Prefix:MR
First Name:KOURTNEY
Middle Name:R
Last Name:PRICE
Suffix:
Gender:M
Credentials:MA, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 HAZELWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-1714
Mailing Address - Country:US
Mailing Address - Phone:313-319-6608
Mailing Address - Fax:
Practice Address - Street 1:1463 BEACONSFIELD AVE APT 2N
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1087
Practice Address - Country:US
Practice Address - Phone:586-359-5269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health