Provider Demographics
NPI:1780806976
Name:CORTEZ, KELLY MARKILLIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARKILLIE
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:HULDA EILEEN
Other - Last Name:MARKILLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:760 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:BERKELEY LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3040
Mailing Address - Country:US
Mailing Address - Phone:770-409-1672
Mailing Address - Fax:
Practice Address - Street 1:4151 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-3232
Practice Address - Country:US
Practice Address - Phone:678-468-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002554101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional