Provider Demographics
NPI:1154090462
Name:SUPPA, COURTNEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SUPPA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-5273
Mailing Address - Country:US
Mailing Address - Phone:320-762-1511
Mailing Address - Fax:
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5273
Practice Address - Country:US
Practice Address - Phone:320-762-1511
Practice Address - Fax:320-762-6857
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2603225100000X
MN12359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist