Provider Demographics
NPI:1508235417
Name:BOURNE, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:BOURNE
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 1:5185 SAINT ANNS RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 NURSING HOME RD
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-2844
Practice Address - Country:US
Practice Address - Phone:573-437-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist