Provider Demographics
NPI:1851646111
Name:BOURASSA, STEPHANIE PAIGE (MSTOM, LAC)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:PAIGE
Last Name:BOURASSA
Suffix:
Gender:F
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:BOURASSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:24-32 UNION SQUARE EAST
Mailing Address - Street 2:SUITE 1115
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:917-744-0417
Mailing Address - Fax:
Practice Address - Street 1:24-32 UNION SQUARE EAST
Practice Address - Street 2:SUITE 115
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:917-744-0417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004684171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist