Provider Demographics
NPI:1194165696
Name:BOURASSA, ALLISON WEHUNT (PT, DPT, NCS, ATC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:WEHUNT
Last Name:BOURASSA
Suffix:
Gender:F
Credentials:PT, DPT, NCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 CHARLES ED ALLEN HALL
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-3429
Mailing Address - Country:US
Mailing Address - Phone:423-439-8275
Mailing Address - Fax:
Practice Address - Street 1:1043 JACK VEST DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614
Practice Address - Country:US
Practice Address - Phone:423-439-4044
Practice Address - Fax:423-439-5264
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN108652251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194165696Medicaid
TNQ078265Medicaid