Provider Demographics
NPI:1093563108
Name:ROYSTER, KOURTNEY JEVON
Entity type:Individual
Prefix:MR
First Name:KOURTNEY
Middle Name:JEVON
Last Name:ROYSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 DURHAM ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2306
Mailing Address - Country:US
Mailing Address - Phone:336-265-6108
Mailing Address - Fax:
Practice Address - Street 1:610 DURHAM ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2306
Practice Address - Country:US
Practice Address - Phone:336-501-6067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health