Provider Demographics
NPI:1811082878
Name:KORTGE, JOEL FREDRIC
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:FREDRIC
Last Name:KORTGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5086 OLD COVE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3817
Mailing Address - Country:US
Mailing Address - Phone:248-623-4834
Mailing Address - Fax:
Practice Address - Street 1:10785 S SAGINAW ST
Practice Address - Street 2:STE. A., BLDG. E
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7003
Practice Address - Country:US
Practice Address - Phone:810-695-0055
Practice Address - Fax:810-695-6813
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009397103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical