Provider Demographics
NPI:1902516586
Name:BOURASSA, MATHIEU (HEARING AID DISPENSE)
Entity Type:Individual
Prefix:
First Name:MATHIEU
Middle Name:
Last Name:BOURASSA
Suffix:
Gender:M
Credentials:HEARING AID DISPENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16814 S 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0763
Mailing Address - Country:US
Mailing Address - Phone:401-207-9700
Mailing Address - Fax:
Practice Address - Street 1:1721 N DYSART RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-1222
Practice Address - Country:US
Practice Address - Phone:623-663-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHADE12739237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist