Basic Information
| Provider Information | |||||||||
| NPI: | 1811082878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORTGE | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | FREDRIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5086 OLD COVE RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483463817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486234834 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10785 S SAGINAW ST | ||||||||
| Address2: | STE. A., BLDG. E | ||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484397003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106950055 | ||||||||
| FaxNumber: | 8106956813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301009397 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.