Provider Demographics
NPI:1720167166
Name:KORNACKI, JANICE MARIE (MA LLP)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:MARIE
Last Name:KORNACKI
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24601 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3106
Mailing Address - Country:US
Mailing Address - Phone:313-792-9284
Mailing Address - Fax:
Practice Address - Street 1:33101 ANNAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-721-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010055103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical