Provider Demographics
NPI:1619389582
Name:MARIN, COURTNEY (LAC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MARIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:MARIN
Other - Last Name:GAUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:4004 SE WOODSTOCK BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7662
Mailing Address - Country:US
Mailing Address - Phone:805-858-8053
Mailing Address - Fax:
Practice Address - Street 1:4004 SE WOODSTOCK BLVD # 5
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7662
Practice Address - Country:US
Practice Address - Phone:805-858-8053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16037171100000X
ORAC180306171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist