Basic Information
Provider Information
NPI: 1003297953
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KING
FirstName: COURTNEY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LMP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 790 REMINGTON BLVD
Address2:  
City: BOLINGBROOK
State: IL
PostalCode: 604404909
CountryCode: US
TelephoneNumber: (630) 296-2223
FaxNumber: 6307599510
Practice Location
Address1: 6985 COAL CREEK PKWY SE
Address2:  
City: NEWCASTLE
State: WA
PostalCode: 980593136
CountryCode: US
TelephoneNumber: 4253780500
FaxNumber: 4253788168
Other Information
ProviderEnumerationDate: 06/16/2015
LastUpdateDate: 07/10/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000XMA60468031WAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


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