Provider Demographics
NPI:1811518533
Name:BOURGET, ALYSSA GRACE (DPT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:GRACE
Last Name:BOURGET
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 FALLIN BLVD APT C5
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4364
Mailing Address - Country:US
Mailing Address - Phone:513-850-3811
Mailing Address - Fax:
Practice Address - Street 1:128 SNOW HILL ST
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513-7237
Practice Address - Country:US
Practice Address - Phone:252-746-8223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist