Provider Demographics
NPI:1962568030
Name:COURSON, BETTY LEE (PTA)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:LEE
Last Name:COURSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:LEE
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3615 LAKE MAYERS RD
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-8537
Mailing Address - Country:US
Mailing Address - Phone:912-367-3551
Mailing Address - Fax:
Practice Address - Street 1:200 S TALLAHASSEE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6024
Practice Address - Country:US
Practice Address - Phone:912-375-7009
Practice Address - Fax:912-375-7055
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA000656225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant