Provider Demographics
NPI:1073198875
Name:COLEY, COURTNEY (LMT, CD, CPD, CBC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:COLEY
Suffix:
Gender:F
Credentials:LMT, CD, CPD, CBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MISTY VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3651
Mailing Address - Country:US
Mailing Address - Phone:605-858-4532
Mailing Address - Fax:
Practice Address - Street 1:205A OLD PERRY RD
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3718
Practice Address - Country:US
Practice Address - Phone:478-365-7857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011527225700000X
GA374J00000X, 174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN