Provider Demographics
NPI:1033596424
Name:WEISS, COURTNEY KATHLEEN (MS, RD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KATHLEEN
Last Name:WEISS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14402 N 20TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-4629
Mailing Address - Country:US
Mailing Address - Phone:708-743-9743
Mailing Address - Fax:
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-6199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86037692133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered