Provider Demographics
NPI:1952445942
Name:BOUSE, VIRGINIA S (P T)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:S
Last Name:BOUSE
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 824
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5007
Mailing Address - Country:US
Mailing Address - Phone:618-234-9705
Mailing Address - Fax:618-257-0665
Practice Address - Street 1:2810 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 824
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5007
Practice Address - Country:US
Practice Address - Phone:618-234-9705
Practice Address - Fax:618-257-0665
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07005126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist