Provider Demographics
NPI:1417775685
Name:BOURISAW, ASHLI (OTD)
Entity type:Individual
Prefix:DR
First Name:ASHLI
Middle Name:
Last Name:BOURISAW
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1689 YELLOW ROCK RD
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-4304
Mailing Address - Country:US
Mailing Address - Phone:618-803-0112
Mailing Address - Fax:
Practice Address - Street 1:3115 S GRAND BLVD STE 224
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1047
Practice Address - Country:US
Practice Address - Phone:314-312-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024039444225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics