Healthcare Provider Details

I. General information

NPI: 1104522770
Provider Name (Legal Business Name): KAROLYN ROSE COULOURIS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39465 W 14 MILE RD
NOVI MI
48377-1600
US

IV. Provider business mailing address

510 HEMPSTEAD TPKE RM 203
WEST HEMPSTEAD NY
11552-1152
US

V. Phone/Fax

Practice location:
  • Phone: 877-906-9699
  • Fax:
Mailing address:
  • Phone: 516-505-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704320977
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: