Provider Demographics
NPI:1174498497
Name:BOURDON, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BOURDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAYFAIR DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72715-5390
Mailing Address - Country:US
Mailing Address - Phone:904-403-4108
Mailing Address - Fax:
Practice Address - Street 1:224 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4544
Practice Address - Country:US
Practice Address - Phone:479-925-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4694225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant