Provider Demographics
NPI:1265693618
Name:BOUSE, ANN MARIKO (PT)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIKO
Last Name:BOUSE
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 1:290 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1002
Mailing Address - Country:US
Mailing Address - Phone:541-951-8390
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:503-570-3665
Practice Address - Fax:503-570-9155
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist