Provider Demographics
NPI:1154896900
Name:COTNER, COURTNEY MICHELLE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MICHELLE
Last Name:COTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9218 LOGANSPORT RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-9373
Mailing Address - Country:US
Mailing Address - Phone:765-432-9506
Mailing Address - Fax:
Practice Address - Street 1:9909 E 100 S
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-9163
Practice Address - Country:US
Practice Address - Phone:765-432-9506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist