Provider Demographics
NPI:1578696340
Name:BOUZAN, LAURIE ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
Last Name:BOUZAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 KALISH AVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-1808
Mailing Address - Country:US
Mailing Address - Phone:860-698-6243
Mailing Address - Fax:
Practice Address - Street 1:305 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-2712
Practice Address - Country:US
Practice Address - Phone:413-525-6361
Practice Address - Fax:413-525-1741
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist