Provider Demographics
NPI:1467753350
Name:ANDERSON, COURTNEY (SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S. DUNCAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-4515
Mailing Address - Country:US
Mailing Address - Phone:727-487-3663
Mailing Address - Fax:
Practice Address - Street 1:808 S. DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4515
Practice Address - Country:US
Practice Address - Phone:727-487-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10899235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004288100Medicaid