Provider Demographics
NPI:1053659649
Name:BOURQUE, MAMAWAH ISATA (PT)
Entity Type:Individual
Prefix:DR
First Name:MAMAWAH
Middle Name:ISATA
Last Name:BOURQUE
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 1:14332 MONTFORT DR
Mailing Address - Street 2:#4101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8486
Mailing Address - Country:US
Mailing Address - Phone:713-256-4708
Mailing Address - Fax:
Practice Address - Street 1:14332 MONTFORT DR
Practice Address - Street 2:#4101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8486
Practice Address - Country:US
Practice Address - Phone:713-256-4708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1210663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist