Provider Demographics
NPI:1245712512
Name:BAINBRIDGE, COURTNEY (PTA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BAINBRIDGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 554
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77572-0554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2615
Practice Address - Country:US
Practice Address - Phone:281-332-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2126826208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation