Provider Demographics
NPI:1134620990
Name:WILSON, COURTNEY BETH
Entity type:Individual
Prefix:MISS
First Name:COURTNEY
Middle Name:BETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 N UNIVERSITY AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-8425
Mailing Address - Country:US
Mailing Address - Phone:801-901-7330
Mailing Address - Fax:
Practice Address - Street 1:363 N UNIVERSITY AVE STE 110
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-8425
Practice Address - Country:US
Practice Address - Phone:801-901-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8043178-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist