Provider Demographics
NPI:1053037333
Name:BALTHAZOR, COURTNEY (SAC-IT)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BALTHAZOR
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 S 9TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-5342
Mailing Address - Country:US
Mailing Address - Phone:920-344-7602
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3767
Practice Address - Country:US
Practice Address - Phone:920-663-1035
Practice Address - Fax:920-215-4918
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20064130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)