Provider Demographics
NPI:1669889325
Name:BOURANIS, CHARLA LARISSA (MED, ATC)
Entity type:Individual
Prefix:
First Name:CHARLA
Middle Name:LARISSA
Last Name:BOURANIS
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LINCOLN HOUSE PT
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2707
Mailing Address - Country:US
Mailing Address - Phone:781-854-1515
Mailing Address - Fax:
Practice Address - Street 1:19 LINCOLN HOUSE PT
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-2707
Practice Address - Country:US
Practice Address - Phone:781-854-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer