MEDICARE: KRISTY KAY EELBODE KRISTY EELBODE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301014265	MI

General Provider Information

NPI Number	:	1205168465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY KAY EELBODE KRISTY EELBODE

Provider Business Mailing Address
First Line	:	18222 HOGAN DR
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-1725
Country	:	US
Telephone Number	:	586-232-3544
Fax Number	:

Provider Business Practice Location Address
First Line	:	2122 15 MILE RD
Second Line	:	SUITE B
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4853
Country	:	US
Telephone Number	:	586-264-3692
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2010
Last Update Date	:	02/12/2010

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