Healthcare Provider Details

I. General information

NPI: 1255962387
Provider Name (Legal Business Name): D.A. COURTNEY LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11156 CANAL RD
CINCINNATI OH
45241-5815
US

IV. Provider business mailing address

1801 WATERMARK DR STE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 513-772-6166
  • Fax:
Mailing address:
  • Phone: 614-487-8758
  • Fax: 614-227-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0800303
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: