Provider Demographics
NPI:1679981484
Name:CARSON DEAN, KORI EILEEN (EDS, MS, SSP, ABSNP)
Entity Type:Individual
Prefix:MS
First Name:KORI
Middle Name:EILEEN
Last Name:CARSON DEAN
Suffix:
Gender:F
Credentials:EDS, MS, SSP, ABSNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 CREEKWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1500
Mailing Address - Country:US
Mailing Address - Phone:810-391-2923
Mailing Address - Fax:810-391-2968
Practice Address - Street 1:1091 CREEKWOOD TRL
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1500
Practice Address - Country:US
Practice Address - Phone:810-391-2923
Practice Address - Fax:810-391-2968
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016021103TC0700X
MISP0000000836585103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical