Healthcare Provider Details

I. General information

NPI: 1619585882
Provider Name (Legal Business Name): KOURTNEY TAYLOR MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KOURTNEY LENZ MA, CCC-SLP

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8175 MOVIE DR
BRIGHTON MI
48116-7444
US

IV. Provider business mailing address

8175 MOVIE DR
BRIGHTON MI
48116-7444
US

V. Phone/Fax

Practice location:
  • Phone: 248-277-3005
  • Fax:
Mailing address:
  • Phone: 248-277-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101008328
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: