Provider Demographics
NPI:1891815809
Name:WILSON, COURTENAY MARTINDALE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:COURTENAY
Middle Name:MARTINDALE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5923 STEPHENS XING
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-6866
Mailing Address - Country:US
Mailing Address - Phone:717-795-8753
Mailing Address - Fax:
Practice Address - Street 1:44 S 38TH ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-4307
Practice Address - Country:US
Practice Address - Phone:717-975-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL003096L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019276990003OtherMEDICAL ASSISTANCE PROVID