Provider Demographics
NPI:1063973436
Name:CORTOLANO, KERI LEIGH
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:LEIGH
Last Name:CORTOLANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 COOL SPRINGS DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5068
Mailing Address - Country:US
Mailing Address - Phone:770-990-6647
Mailing Address - Fax:
Practice Address - Street 1:1414 DUG GAP RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-5007
Practice Address - Country:US
Practice Address - Phone:706-379-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009227101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health