Provider Demographics
NPI:1851152391
Name:WILSON, COURTNEY MARIE (RD, LD, CDCES)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD, LD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SPRING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-2244
Mailing Address - Country:US
Mailing Address - Phone:214-543-9182
Mailing Address - Fax:
Practice Address - Street 1:700 SPRING LAKE DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-2244
Practice Address - Country:US
Practice Address - Phone:214-543-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07551133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered