Healthcare Provider Details

I. General information

NPI: 1427940683
Provider Name (Legal Business Name): KOURTNEY LANAE GARY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51111 WOODWARD AVE STE 150
PONTIAC MI
48342-5037
US

IV. Provider business mailing address

16526 BIRWOOD ST STE 150
DETROIT MI
48221-2804
US

V. Phone/Fax

Practice location:
  • Phone: 248-254-2616
  • Fax:
Mailing address:
  • Phone: 248-254-2616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: