Provider Demographics
NPI:1902004070
Name:KOELTZOW, DEBBIE (EDD, LP)
Entity Type:Individual
Prefix:DR
First Name:DEBBIE
Middle Name:
Last Name:KOELTZOW
Suffix:
Gender:F
Credentials:EDD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 CARRIAGE WAY
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7423
Mailing Address - Country:US
Mailing Address - Phone:734-657-8059
Mailing Address - Fax:810-588-4247
Practice Address - Street 1:810 E GRAND RIVER AVE
Practice Address - Street 2:#101
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1878
Practice Address - Country:US
Practice Address - Phone:810-588-4236
Practice Address - Fax:810-588-4247
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011430103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68OH113370OtherBC/BC OF MICHIGAN
MI143449OtherVALUE OPTIONS
MI382695674OtherPPOM
MI382695674OtherCIGNA BEHAVIORAL HEALTH