Provider Demographics
NPI:1194120626
Name:BOURDON, JOAN ELAINE (PT)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:ELAINE
Last Name:BOURDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:ELAINE
Other - Last Name:SHALLCROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:900 S. FRANKLIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2797
Mailing Address - Country:US
Mailing Address - Phone:919-556-1700
Mailing Address - Fax:919-556-1245
Practice Address - Street 1:900 S. FRANKLIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2797
Practice Address - Country:US
Practice Address - Phone:919-556-1700
Practice Address - Fax:919-556-1245
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist