Provider Demographics
NPI:1033999347
Name:VANDER WAL, COURTNEY
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:
Last Name:VANDER WAL
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 1:3246 BALSAM ST SW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6625 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2373
Practice Address - Country:US
Practice Address - Phone:952-285-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107299225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist