Provider Demographics
NPI:1306962600
Name:BAUER, COURTNEY SCOTT (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:SCOTT
Last Name:BAUER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:MARIE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:8680 BELL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6223
Mailing Address - Country:US
Mailing Address - Phone:662-895-4555
Mailing Address - Fax:
Practice Address - Street 1:5779 GETWELL RD
Practice Address - Street 2:BLDG. D, SUITE 3
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6347
Practice Address - Country:US
Practice Address - Phone:662-510-6507
Practice Address - Fax:662-510-6508
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3071235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07834592Medicaid