Provider Demographics
NPI:1962775544
Name:HARRIS, COURTNEY VAN (DPT)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:VAN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2840
Mailing Address - Country:US
Mailing Address - Phone:850-445-4398
Mailing Address - Fax:
Practice Address - Street 1:1100 S STRATFORD RD
Practice Address - Street 2:100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3217
Practice Address - Country:US
Practice Address - Phone:336-768-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12373172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker