Provider Demographics
NPI:1710367313
Name:TODD, CORTLYN BROOKE (ATC, EMT-B)
Entity Type:Individual
Prefix:
First Name:CORTLYN
Middle Name:BROOKE
Last Name:TODD
Suffix:
Gender:F
Credentials:ATC, EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1997
Mailing Address - Country:US
Mailing Address - Phone:859-200-2485
Mailing Address - Fax:
Practice Address - Street 1:712 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1997
Practice Address - Country:US
Practice Address - Phone:859-200-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1116690146N00000X
KYAT12252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic