Provider Demographics
NPI:1770265969
Name:PHOENIX, COURTNEY LEIGH
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEIGH
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CECE
Other - Middle Name:
Other - Last Name:PHOENIX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:620 NE 20TH AVE APT 421
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 NE 20TH AVE APT 421
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3544
Practice Address - Country:US
Practice Address - Phone:971-420-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108657172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker