Provider Demographics
NPI:1922675784
Name:OTWELL, COURTNEY (MS)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:OTWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12481 ARROWLEAF LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6847
Mailing Address - Country:US
Mailing Address - Phone:904-537-0225
Mailing Address - Fax:
Practice Address - Street 1:8703 HIGHWAY 17 BYP S
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-7701
Practice Address - Country:US
Practice Address - Phone:843-457-1053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC253Z00000X235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist