Provider Demographics
NPI:1316253735
Name:GARRISON, COURTNEY STEVENS- (CPED)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:STEVENS-
Last Name:GARRISON
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W ROOSEVELT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3762
Mailing Address - Country:US
Mailing Address - Phone:704-225-0285
Mailing Address - Fax:704-225-0287
Practice Address - Street 1:1900 W ROOSEVELT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3762
Practice Address - Country:US
Practice Address - Phone:704-225-0285
Practice Address - Fax:704-225-0287
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPED3196213EP0504X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704221Medicaid
NC7704221Medicaid