Provider Demographics
NPI:1013214816
Name:BOURASSA, MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOURASSA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4312
Mailing Address - Country:US
Mailing Address - Phone:904-757-1782
Mailing Address - Fax:904-757-9808
Practice Address - Street 1:310 DUNDAS DR
Practice Address - Street 2:SUITE 8
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-5588
Practice Address - Country:US
Practice Address - Phone:904-757-1782
Practice Address - Fax:904-757-9808
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP13029225100000X
FL27105225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist