Provider Demographics
NPI:1548801541
Name:FITZGERALD, COURTNEY FERRIS (SLP)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:FERRIS
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:FERRIS
Other - Last Name:DREILING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14464 KOMEDAL RD NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1021
Mailing Address - Country:US
Mailing Address - Phone:951-333-2801
Mailing Address - Fax:
Practice Address - Street 1:9343 SPORTSMAN CLUB RD NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-3642
Practice Address - Country:US
Practice Address - Phone:206-780-6520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP15986235Z00000X
WALL60886875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP15986OtherCALIFORNIA STATE SLP, AUD, AND HEARING AID DISPERNSERS BOARD
WA560428EOtherSTATE OF WA OSPI
WALL60886875OtherWA DEPT OF HEALTH