Provider Demographics
NPI:1912316530
Name:BOULWARE, MORGAN ALEXANDRA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:ALEXANDRA
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:ALEXANDRA
Other - Last Name:HOLEKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-8907
Mailing Address - Fax:423-954-7408
Practice Address - Street 1:4833 HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-1826
Practice Address - Country:US
Practice Address - Phone:423-553-7972
Practice Address - Fax:423-553-7973
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10117225100000X
ALPTH7299225100000X
GAPT011693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-54899OtherBCBS-WEST MADISON
AL511-54897OtherBCBS-CHELSEA
002422OtherOPTUM
AL102I652175OtherMEDICARE PTAN
AL511-54898OtherBCBS-MOODY
AL511-54895OtherBCBS-ATHENS
AL511-56409OtherBCBS-ALTADENA
AL511-54896OtherBCBS-HOOVER