Provider Demographics
NPI:1538664560
Name:KINNAMON, COURTNEY PAIGE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:PAIGE
Last Name:KINNAMON
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 1:102 DAWN LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9695
Mailing Address - Country:US
Mailing Address - Phone:740-947-7783
Mailing Address - Fax:740-947-4226
Practice Address - Street 1:102 DAWN LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9695
Practice Address - Country:US
Practice Address - Phone:740-947-7783
Practice Address - Fax:740-947-4226
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161312101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)