Provider Demographics
NPI:1003195058
Name:RICARD, COURTNEY LYNN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:RICARD
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 1:9151 FRENCHMANS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-1537
Mailing Address - Country:US
Mailing Address - Phone:315-695-5111
Mailing Address - Fax:
Practice Address - Street 1:9151 FRENCHMANS CREEK DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:NY
Practice Address - Zip Code:13135-1537
Practice Address - Country:US
Practice Address - Phone:315-695-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007915224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant