Provider Demographics
NPI:1982152146
Name:IVERSON, KOURTNIE J MICHELLE (LSW)
Entity type:Individual
Prefix:
First Name:KOURTNIE
Middle Name:J MICHELLE
Last Name:IVERSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1791 ALUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1708
Mailing Address - Country:US
Mailing Address - Phone:614-445-8131
Mailing Address - Fax:614-827-8380
Practice Address - Street 1:60 N STYGLER RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-2435
Practice Address - Country:US
Practice Address - Phone:614-475-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS15006951041C0700X
OHI.21028731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0283825Medicaid