Provider Demographics
NPI:1558767483
Name:BOURCY, SAMANTHA (MATRG, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BOURCY
Suffix:
Gender:F
Credentials:MATRG, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 17TH AVE E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-5273
Mailing Address - Country:US
Mailing Address - Phone:320-762-1144
Mailing Address - Fax:320-762-1935
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:SUITE 101
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5273
Practice Address - Country:US
Practice Address - Phone:320-762-1144
Practice Address - Fax:320-762-1935
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND503-132255A2300X
MN26342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer