Provider Demographics
NPI:1689866790
Name:COURTNEY, MARK ALAN (PROVIDER)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:COURTNEY
Suffix:
Gender:M
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2081
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2081
Mailing Address - Country:US
Mailing Address - Phone:307-527-4616
Mailing Address - Fax:
Practice Address - Street 1:2508 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9797
Practice Address - Country:US
Practice Address - Phone:307-527-4616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child