Provider Demographics
NPI:1962106443
Name:WILLIAMS GIBSON, COURTNEY DESHAWN (CTRS)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:DESHAWN
Last Name:WILLIAMS GIBSON
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 1:6060 WINCHESTER AVE TRLR 82
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-1870
Mailing Address - Country:US
Mailing Address - Phone:225-346-2418
Mailing Address - Fax:
Practice Address - Street 1:6060 WINCHESTER AVE TRLR 82
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-1870
Practice Address - Country:US
Practice Address - Phone:225-346-2418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA83416225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist