Basic Information
| Provider Information | |||||||||
| NPI: | 1275730624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVERAGE ASH | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | WENDELL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7401 S. MAIN | ||||||||
| Address2: | FONDREN ORTHOPEDIC GROUP L.L.P | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137992300 | ||||||||
| FaxNumber: | 7137943380 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ROCKMEAD DRIVE | ||||||||
| Address2: | |||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813595115 | ||||||||
| FaxNumber: | 2813592663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 009732 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 002123 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1175853 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 365496 | 05 | OH | MEDICAID |