Provider Demographics
NPI:1699339424
Name:ERNST, COURTNEY CAMPBELL (PTA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CAMPBELL
Last Name:ERNST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 ELK LN
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8214
Mailing Address - Country:US
Mailing Address - Phone:951-317-5812
Mailing Address - Fax:970-984-0587
Practice Address - Street 1:820 CASTLE VALLEY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:CO
Practice Address - Zip Code:81647-9453
Practice Address - Country:US
Practice Address - Phone:970-984-2300
Practice Address - Fax:970-984-0587
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97022081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9072OtherPTA LISENCE