Provider Demographics
NPI:1104466739
Name:BOURASSA, HEATHER DAWN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:BOURASSA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 GURNEY CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3416
Mailing Address - Country:US
Mailing Address - Phone:314-599-4050
Mailing Address - Fax:
Practice Address - Street 1:15875 NEW HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1225
Practice Address - Country:US
Practice Address - Phone:314-953-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019045240235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist