Provider Demographics
NPI:1578725966
Name:BLEVINS, COURTNEY LANGE
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:LANGE
Last Name:BLEVINS
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 1:2603 OSBORNE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-2326
Mailing Address - Country:US
Mailing Address - Phone:276-669-6331
Mailing Address - Fax:
Practice Address - Street 1:2603 OSBORNE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-2326
Practice Address - Country:US
Practice Address - Phone:276-669-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005355235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist