Provider Demographics
NPI:1629531223
Name:MOELLER, COURTNEY L (ATC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:MOELLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 PINELAWN DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3534
Mailing Address - Country:US
Mailing Address - Phone:419-509-5802
Mailing Address - Fax:
Practice Address - Street 1:1610 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43403-4302
Practice Address - Country:US
Practice Address - Phone:419-509-5802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0053362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer