Provider Demographics
NPI:1528542438
Name:ELLIOTT, KOURTNEE (MA, TLLP)
Entity Type:Individual
Prefix:
First Name:KOURTNEE
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44899 CENTRE CT STE 101
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5510
Mailing Address - Country:US
Mailing Address - Phone:586-690-8331
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:248-251-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362000433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical