Provider Demographics
NPI:1053876276
Name:EKSTROM, KORI A (QMHS)
Entity type:Individual
Prefix:
First Name:KORI
Middle Name:A
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 FREEDOM DR
Mailing Address - Street 2:
Mailing Address - City:NAPOLEON
Mailing Address - State:OH
Mailing Address - Zip Code:43545-9038
Mailing Address - Country:US
Mailing Address - Phone:419-599-1660
Mailing Address - Fax:
Practice Address - Street 1:600 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9038
Practice Address - Country:US
Practice Address - Phone:419-599-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health