Provider Demographics
NPI:1417662776
Name:MASK, COURTNEY (MS, RD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MASK
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:MI
Mailing Address - Zip Code:48429-1411
Mailing Address - Country:US
Mailing Address - Phone:989-627-6505
Mailing Address - Fax:
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-6099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86169568133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINAOtherNA