Healthcare Provider Details

I. General information

NPI: 1538951280
Provider Name (Legal Business Name): COURTNEY ANDERS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 PERIMETER DR
MOSCOW ID
83844-9803
US

IV. Provider business mailing address

1900 RICHAL DR
SAINT PAUL MN
55125-1536
US

V. Phone/Fax

Practice location:
  • Phone: 651-231-3593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: