Healthcare Provider Details

I. General information

NPI: 1245342526
Provider Name (Legal Business Name): MICHAEL LEE COURTER JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E MAIN ST
DANVILLE IL
61832-5100
US

IV. Provider business mailing address

605 SHERWOOD DR
SAINT JOSEPH IL
61873-9457
US

V. Phone/Fax

Practice location:
  • Phone: 217-554-4259
  • Fax:
Mailing address:
  • Phone: 217-649-5064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-006165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: