Healthcare Provider Details

I. General information

NPI: 1881862910
Provider Name (Legal Business Name): COURTNEY LYNN DONALDSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BRICKSTONE SQ STE 301
ANDOVER MA
01810-1429
US

IV. Provider business mailing address

WISHING WELL HEALTH CENTER 1539 COUNTRY CLUB ROAD
FAIRMONT WV
26554
US

V. Phone/Fax

Practice location:
  • Phone: 978-474-7500
  • Fax:
Mailing address:
  • Phone: 304-366-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1324
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: