Provider Demographics
NPI:1669003646
Name:KORNACK, OLIVIA NOEL (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NOEL
Last Name:KORNACK
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23404 CROSSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1669
Mailing Address - Country:US
Mailing Address - Phone:586-822-3977
Mailing Address - Fax:
Practice Address - Street 1:26657 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1371
Practice Address - Country:US
Practice Address - Phone:586-822-3977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017951101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2049255OtherCOUNSELING