Healthcare Provider Details

I. General information

NPI: 1265490304
Provider Name (Legal Business Name): COURTNEY TAYLOR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 W EVERGREEN AVE
EFFINGHAM IL
62401-1619
US

IV. Provider business mailing address

1729 E MAIN ST
SALEM IL
62881-3530
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-3400
  • Fax:
Mailing address:
  • Phone: 618-548-0987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: