Provider Demographics
NPI:1801338066
Name:PHILLIPS, COURTNEY (ATC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 LONE PINE BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-9403
Mailing Address - Country:US
Mailing Address - Phone:541-506-6500
Mailing Address - Fax:540-506-6501
Practice Address - Street 1:551 LONE PINE BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-9403
Practice Address - Country:US
Practice Address - Phone:541-506-6500
Practice Address - Fax:540-506-6501
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-101454022255A2300X
WAA1605128202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer