Basic Information
| Provider Information | |||||||||
| NPI: | 1053711135 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KORTANEK PSYCHOLOGICAL SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24800 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225648 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 24800 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162456231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2014 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | KORTANEK | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2162456231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6995 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.