Provider Demographics
NPI:1558819854
Name:MOORE, COURTNEY (CTRS)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 RYAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-2239
Mailing Address - Country:US
Mailing Address - Phone:616-520-7183
Mailing Address - Fax:
Practice Address - Street 1:1837 RYAN AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-2239
Practice Address - Country:US
Practice Address - Phone:616-520-7183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63262225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist