Basic Information
| Provider Information | |||||||||
| NPI: | 1851402507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 STOUT DRIVEBOX 70403 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394515 | ||||||||
| FaxNumber: | 4234394060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2151 CENTURY LANE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239262500 | ||||||||
| FaxNumber: | 4239265999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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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 | 003628 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2375 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT9474 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT9474 | 01 | TN | ST LICENSE | OTHER |