Healthcare Provider Details

I. General information

NPI: 1154090462
Provider Name (Legal Business Name): COURTNEY SUPPA PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1511
  • Fax: 320-762-6857
Mailing address:
  • Phone: 320-762-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2603
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12359
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: