Provider Demographics
NPI:1477106235
Name:BOURLET, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BOURLET
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 1:41043 SNOWBALL CIR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-8420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41043 SNOWBALL CIR
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-8420
Practice Address - Country:US
Practice Address - Phone:239-293-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10249225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant