Provider Demographics
NPI:1710717053
Name:SUPPLE, COURTNEY R (LCSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:SUPPLE
Suffix:
Gender:X
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 OLD LYMAN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-2663
Mailing Address - Country:US
Mailing Address - Phone:413-564-9617
Mailing Address - Fax:
Practice Address - Street 1:51 OLD LYMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-2663
Practice Address - Country:US
Practice Address - Phone:413-564-9617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW2303641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical