Provider Demographics
NPI:1083072144
Name:COLE-HACKWORTH, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:COLE-HACKWORTH
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 1:279 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:POUNDING MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24637-4054
Mailing Address - Country:US
Mailing Address - Phone:276-971-1771
Mailing Address - Fax:
Practice Address - Street 1:279 FAIR ST
Practice Address - Street 2:
Practice Address - City:POUNDING MILL
Practice Address - State:VA
Practice Address - Zip Code:24637-4054
Practice Address - Country:US
Practice Address - Phone:276-971-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty