Provider Demographics
NPI:1033749312
Name:BOURYOU, IMAN (PT)
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:BOURYOU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 ARCADIA DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-3619
Mailing Address - Country:US
Mailing Address - Phone:954-662-4060
Mailing Address - Fax:
Practice Address - Street 1:5901 NW 79TH AVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4639
Practice Address - Country:US
Practice Address - Phone:954-722-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist