Provider Demographics
NPI:1871817361
Name:MODESITT, COURTNEY LEE (MS,OT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEE
Last Name:MODESITT
Suffix:
Gender:F
Credentials:MS,OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 TOMMY AARON DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1504
Mailing Address - Country:US
Mailing Address - Phone:770-503-7337
Mailing Address - Fax:770-503-7337
Practice Address - Street 1:634 TOMMY AARON DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-1504
Practice Address - Country:US
Practice Address - Phone:770-503-7337
Practice Address - Fax:770-503-7337
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004984225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics