Provider Demographics
NPI:1508285289
Name:BOURGEON, LAETITIA (DPT)
Entity Type:Individual
Prefix:
First Name:LAETITIA
Middle Name:
Last Name:BOURGEON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 PEBBLE BEACH RD
Mailing Address - Street 2:APT 5
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8550
Mailing Address - Country:US
Mailing Address - Phone:501-428-3249
Mailing Address - Fax:
Practice Address - Street 1:3315 PEBBLE BEACH RD
Practice Address - Street 2:APT 5
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8550
Practice Address - Country:US
Practice Address - Phone:501-428-3249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist