Provider Demographics
NPI:1154751048
Name:SMITH, COURTNEY
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:M
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:2079 NEWPORT DRIVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707
Mailing Address - Country:US
Mailing Address - Phone:912-585-2963
Mailing Address - Fax:
Practice Address - Street 1:2079 NEWPORT DRIVE
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707
Practice Address - Country:US
Practice Address - Phone:912-585-2963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003906133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered