Provider Demographics
NPI:1275155020
Name:ECCLES, COURTNEY NICOLE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:ECCLES
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 1:888 KELLY PASS
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-5572
Mailing Address - Country:US
Mailing Address - Phone:317-460-2925
Mailing Address - Fax:
Practice Address - Street 1:5080 N STATE ROAD 135 STE F
Practice Address - Street 2:
Practice Address - City:BARGERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46106-8931
Practice Address - Country:US
Practice Address - Phone:317-893-2449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004532A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant