Provider Demographics
NPI:1164057097
Name:TAYLOR, COURTNEY ALEA
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ALEA
Last Name:TAYLOR
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 1:339 N BRADLEY DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1642
Mailing Address - Country:US
Mailing Address - Phone:708-793-3638
Mailing Address - Fax:
Practice Address - Street 1:339 N BRADLEY DR
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1642
Practice Address - Country:US
Practice Address - Phone:708-793-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056013496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist