Provider Demographics
NPI:1699255679
Name:BOUSARD, SHANA REBILAS (MT-BC)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:REBILAS
Last Name:BOUSARD
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40850 N TRAILHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-4941
Mailing Address - Country:US
Mailing Address - Phone:623-810-3242
Mailing Address - Fax:
Practice Address - Street 1:40850 N TRAILHEAD WAY
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-4941
Practice Address - Country:US
Practice Address - Phone:623-810-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist