Provider Demographics
NPI:1619207149
Name:ROBERTSON, COURTNEY WILLIFORD (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:WILLIFORD
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:WILLIFORD
Other - Last Name:COSTAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:709 BENNINGTON ST
Mailing Address - Street 2:#3
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1153
Mailing Address - Country:US
Mailing Address - Phone:617-418-5606
Mailing Address - Fax:
Practice Address - Street 1:130 CONDOR ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1305
Practice Address - Country:US
Practice Address - Phone:617-569-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7828235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist