Provider Demographics
NPI:1649612581
Name:BURNS, AMY M (DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:BURNS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:BOUGOUKALOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:163 N MARENGO AVE
Mailing Address - Street 2:#402
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-4509
Mailing Address - Country:US
Mailing Address - Phone:209-485-4358
Mailing Address - Fax:
Practice Address - Street 1:4733 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6021
Practice Address - Country:US
Practice Address - Phone:323-783-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist