Provider Demographics
NPI:1467968313
Name:BOURDELAIS, RYAN PATRICK
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:BOURDELAIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 PINK DOGWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54313-3241
Mailing Address - Country:US
Mailing Address - Phone:715-923-1080
Mailing Address - Fax:
Practice Address - Street 1:200 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1393
Practice Address - Country:US
Practice Address - Phone:920-338-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6155225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist