Provider Demographics
NPI:1326550336
Name:GAUTZ, JOURNEE ELIZABETH
Entity Type:Individual
Prefix:
First Name:JOURNEE
Middle Name:ELIZABETH
Last Name:GAUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23400 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1924
Mailing Address - Country:US
Mailing Address - Phone:313-689-5188
Mailing Address - Fax:
Practice Address - Street 1:23400 MICHIGAN AVE STE P40
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1928
Practice Address - Country:US
Practice Address - Phone:313-689-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900747294Medicaid