Provider Demographics
NPI:1194307082
Name:BOU, NATHAN JEFFERY (LMT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JEFFERY
Last Name:BOU
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24644 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2421
Mailing Address - Country:US
Mailing Address - Phone:734-748-2847
Mailing Address - Fax:
Practice Address - Street 1:4015 N BLAIR AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2709
Practice Address - Country:US
Practice Address - Phone:248-385-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501012012225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist