Provider Demographics
NPI:1134940067
Name:WOOTEN, KORTNEY DANIELLE (PHD)
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:DANIELLE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 WEST LOOP 289
Mailing Address - Street 2:APARTMENT 104 BUILDING 23
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407
Mailing Address - Country:US
Mailing Address - Phone:225-328-7511
Mailing Address - Fax:
Practice Address - Street 1:2102 WEST LOOP 289
Practice Address - Street 2:APARTMENT 104 BUILDING 23
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407
Practice Address - Country:US
Practice Address - Phone:225-328-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40206103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling