Provider Demographics
NPI:1235643024
Name:GONDREAU, COURTNI (LAC)
Entity Type:Individual
Prefix:
First Name:COURTNI
Middle Name:
Last Name:GONDREAU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:COURTNI
Other - Middle Name:
Other - Last Name:GONDREAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:310 S. JEFFERSON ST.
Mailing Address - Street 2:
Mailing Address - City:ST. CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5230 E SHEA BLVD FL 1
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5750
Practice Address - Country:US
Practice Address - Phone:480-876-9409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1804171100000X
AZLAC-011382171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist