Provider Demographics
NPI:1801076658
Name:BOURGEOIS, KRISTY TROSCLAIR (PT)
Entity type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:TROSCLAIR
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:L
Other - Last Name:TROSCLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 CANE BREAK DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-3981
Mailing Address - Country:US
Mailing Address - Phone:985-872-5911
Mailing Address - Fax:985-872-6155
Practice Address - Street 1:478 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2461
Practice Address - Country:US
Practice Address - Phone:985-872-5911
Practice Address - Fax:985-872-6155
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A706CC88Medicare PIN