Provider Demographics
NPI:1770085094
Name:CORTELLI, KRISTA (RBT-17-38915)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:CORTELLI
Suffix:
Gender:F
Credentials:RBT-17-38915
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41012 NORTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1320
Mailing Address - Country:US
Mailing Address - Phone:734-765-2673
Mailing Address - Fax:
Practice Address - Street 1:41012 NORTHWIND DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1320
Practice Address - Country:US
Practice Address - Phone:734-765-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17-38915106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician