Provider Demographics
NPI:1205168465
Name:EELBODE, KRISTY KAY (KRISTY EELBODE)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:KAY
Last Name:EELBODE
Suffix:
Gender:F
Credentials:KRISTY EELBODE
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:KAY
Other - Last Name:OWCZARSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TLLP
Mailing Address - Street 1:18222 HOGAN DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-1725
Mailing Address - Country:US
Mailing Address - Phone:586-232-3544
Mailing Address - Fax:
Practice Address - Street 1:2122 15 MILE RD
Practice Address - Street 2:SUITE B
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4853
Practice Address - Country:US
Practice Address - Phone:586-264-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014265103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical