Provider Demographics
NPI:1124215512
Name:SMALLEY, COURTNEY L (PTA)
Entity Type:Individual
Prefix:MR
First Name:COURTNEY
Middle Name:L
Last Name:SMALLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 WOODYCREST AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-3729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 5TH AVE
Practice Address - Street 2:SUITE 5115
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10118-0110
Practice Address - Country:US
Practice Address - Phone:866-601-6474
Practice Address - Fax:212-928-9545
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006597-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006597-1OtherSTATE LISCENSE