Provider Demographics
NPI:1215574223
Name:WILSON, COURTNEY E
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:E
Last Name:WILSON
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 1:26761 S BROOKS LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97004-8842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12901 SE 97TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7901
Practice Address - Country:US
Practice Address - Phone:971-206-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician