Provider Demographics
NPI:1932572849
Name:KURTZ, TERRIA
Entity Type:Individual
Prefix:
First Name:TERRIA
Middle Name:
Last Name:KURTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERRIA
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:501 DAVISON RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423
Mailing Address - Country:US
Mailing Address - Phone:810-991-4464
Mailing Address - Fax:
Practice Address - Street 1:501 DAVISON RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423
Practice Address - Country:US
Practice Address - Phone:810-991-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010927691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3833CMedicaid
MI13189Medicaid