Provider Demographics
NPI:1760121420
Name:MOYLE, COURTNEE RAE (LMT)
Entity Type:Individual
Prefix:
First Name:COURTNEE
Middle Name:RAE
Last Name:MOYLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-6003
Mailing Address - Country:US
Mailing Address - Phone:208-790-8759
Mailing Address - Fax:
Practice Address - Street 1:THE GYM
Practice Address - Street 2:1005 ID-13
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530
Practice Address - Country:US
Practice Address - Phone:208-790-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4748225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist