Provider Demographics
NPI:1144008053
Name:DOLAN, COURTNEY KILLEEN (LMT# 26995)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KILLEEN
Last Name:DOLAN
Suffix:
Gender:F
Credentials:LMT# 26995
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 NE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6204
Mailing Address - Country:US
Mailing Address - Phone:503-929-7606
Mailing Address - Fax:
Practice Address - Street 1:2031 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2812
Practice Address - Country:US
Practice Address - Phone:503-893-2275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26995225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist