Provider Demographics
NPI:1194368712
Name:DONALD, COURTNEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DONALD
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:FRIESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:8043 GREENLEAF TER APT 14
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4948
Mailing Address - Country:US
Mailing Address - Phone:717-414-9677
Mailing Address - Fax:
Practice Address - Street 1:14000 JERICHO PARK RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-3319
Practice Address - Country:US
Practice Address - Phone:717-414-9677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260032912255A2300X
PART0064802255A2300X
MDA00009602255A2300X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer