Provider Demographics
NPI:1295037216
Name:VAN DOREN, KOURTNE
Entity Type:Individual
Prefix:
First Name:KOURTNE
Middle Name:
Last Name:VAN DOREN
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 1:2401 NORTHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2409 STONEHENGE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6480
Practice Address - Country:US
Practice Address - Phone:405-850-3346
Practice Address - Fax:405-850-3346
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK235Z00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist