Provider Demographics
NPI:1770209702
Name:BOURASSA, SPENCER ANDREW (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:ANDREW
Last Name:BOURASSA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 RUSTIC LN
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:ME
Mailing Address - Zip Code:04002-6042
Mailing Address - Country:US
Mailing Address - Phone:207-590-9179
Mailing Address - Fax:
Practice Address - Street 1:9394 W DODGE RD STE 300
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3319
Practice Address - Country:US
Practice Address - Phone:800-732-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT39406225100000X
MA26806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT39406OtherFLORIDA PT LICENSE NUMBER