=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831482587
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY L WITHERSPOON D.O.M, L.AC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2011
-----------------------------------------------------
Last Update Date | 05/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2186 5TH AVE APT 1P
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10037-2708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-252-2802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 244 5TH AVE STE 1783
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 000463-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------