Healthcare Provider Details

I. General information

NPI: 1275155020
Provider Name (Legal Business Name): COURTNEY NICOLE ECCLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 N STATE ROAD 135 STE F
BARGERSVILLE IN
46106-8931
US

IV. Provider business mailing address

888 KELLY PASS
GREENWOOD IN
46143-5572
US

V. Phone/Fax

Practice location:
  • Phone: 317-893-2449
  • Fax:
Mailing address:
  • Phone: 317-460-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004532A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: