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General NPI Number Information
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NPI Number | 1205168465
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Entity Type | Individual
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Provider Name | KRISTY KAY EELBODE KRISTY EELBODE
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Gender | Female
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Dates
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Enumeration Date | 02/12/2010
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Last Update Date | 02/12/2010
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Provider Practice Location Address
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Address Line | 2122 15 MILE RD SUITE B
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City | STERLING HEIGHTS
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State | MI
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Zip | 48310-4853
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Country | US
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Telephone | 586-264-3692
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Fax |
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Provider Business Mailing Address
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Address Line | 18222 HOGAN DR
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City | MACOMB
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State | MI
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Zip | 48042-1725
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Country | US
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Telephone | 586-232-3544
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301014265
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License Number State | MI
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