Provider Demographics
NPI:1558960831
Name:WATHEN, KOURTNEY
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:WATHEN
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 1:10130 PENNS HILL RD
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-4536
Mailing Address - Country:US
Mailing Address - Phone:240-427-7568
Mailing Address - Fax:
Practice Address - Street 1:4240 ALTAMONT PL
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3052
Practice Address - Country:US
Practice Address - Phone:301-893-2345
Practice Address - Fax:301-638-1783
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10043235Z00000X
DCSLP200001316235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist