Healthcare Provider Details

I. General information

NPI: 1982111241
Provider Name (Legal Business Name): COURTNAY WILSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 SHIELDS DR
BENNINGTON VT
05201-9810
US

IV. Provider business mailing address

357 SHIELDS DR
BENNINGTON VT
05201-9810
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-1409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number048.0132465
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: