Basic Information
Provider Information | |||||||||
NPI: | 1174113856 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILLETT | ||||||||
FirstName: | KOURTNEY | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 760 CENTRAL PARK CT APT 220 | ||||||||
Address2: |   | ||||||||
City: | PLAINFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461682751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3057207631 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6655 E US HIGHWAY 36 | ||||||||
Address2: |   | ||||||||
City: | AVON | ||||||||
State: | IN | ||||||||
PostalCode: | 461238923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887141927 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2021 | ||||||||
LastUpdateDate: | 01/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 33009946A | IN | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 150104357 | IL | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.