Healthcare Provider Details

I. General information

NPI: 1912596768
Provider Name (Legal Business Name): COURTNEY PAULA TATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 TRINITY AVE
SPRING VALLEY NY
10977-3024
US

IV. Provider business mailing address

5 TRINITY AVE
SPRING VALLEY NY
10977-3024
US

V. Phone/Fax

Practice location:
  • Phone: 845-826-1700
  • Fax:
Mailing address:
  • Phone: 845-826-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number330027671
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number330027671
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: