Provider Demographics
NPI:1043235856
Name:MIKESELL, COURTNEY L (COTA)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:L
Last Name:MIKESELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-2512
Mailing Address - Country:US
Mailing Address - Phone:814-765-4973
Mailing Address - Fax:
Practice Address - Street 1:1229 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-3305
Practice Address - Country:US
Practice Address - Phone:814-765-0221
Practice Address - Fax:814-765-3011
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003649L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist