Provider Demographics
NPI:1346067386
Name:ANDERSON, COURTNEY (OTR/L)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 CUMBERLAND TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-7300
Mailing Address - Country:US
Mailing Address - Phone:262-215-6965
Mailing Address - Fax:
Practice Address - Street 1:965 CUMBERLAND TRL
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-7300
Practice Address - Country:US
Practice Address - Phone:262-215-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8640-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty