Healthcare Provider Details

I. General information

NPI: 1952206963
Provider Name (Legal Business Name): COURTNEY R CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 PEBBLEBROOK CT
BLOOMINGTON IL
61705-6300
US

IV. Provider business mailing address

46 PEBBLEBROOK CT
BLOOMINGTON IL
61705-6300
US

V. Phone/Fax

Practice location:
  • Phone: 309-336-9016
  • Fax:
Mailing address:
  • Phone: 309-336-9016
  • 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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: