Provider Demographics
NPI:1336292317
Name:BOUR, BARBARA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:JEAN
Last Name:BOUR
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 1:2028 MICHIGAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-3408
Mailing Address - Country:US
Mailing Address - Phone:727-692-0578
Mailing Address - Fax:
Practice Address - Street 1:2028 MICHIGAN AVE NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-3408
Practice Address - Country:US
Practice Address - Phone:727-692-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8803501Medicaid