Provider Demographics
NPI:1770170912
Name:ALLEN, COURTNEY DAWN (PTA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DAWN
Last Name:ALLEN
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 1:1421 W FROSTY DR APT 2
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-9476
Mailing Address - Country:US
Mailing Address - Phone:417-718-9966
Mailing Address - Fax:
Practice Address - Street 1:1707 W ELFINDALE ST # SR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1295
Practice Address - Country:US
Practice Address - Phone:417-831-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020021914225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant