Provider Demographics
NPI:1669988820
Name:BOURASSA, MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOURASSA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3058 N STATE RD STE E
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-3508
Mailing Address - Country:US
Mailing Address - Phone:810-652-6315
Mailing Address - Fax:810-652-6213
Practice Address - Street 1:3058 N STATE RD STE E
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-3508
Practice Address - Country:US
Practice Address - Phone:810-652-6315
Practice Address - Fax:810-652-6213
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010287225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist