Provider Demographics
NPI:1053075192
Name:SANSONE, COURTNEE RYEN
Entity Type:Individual
Prefix:
First Name:COURTNEE
Middle Name:RYEN
Last Name:SANSONE
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 1:301 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62012-1346
Mailing Address - Country:US
Mailing Address - Phone:618-407-8873
Mailing Address - Fax:
Practice Address - Street 1:301 N MARKET ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:IL
Practice Address - Zip Code:62012-1346
Practice Address - Country:US
Practice Address - Phone:618-407-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL005580224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant