Provider Demographics
NPI:1033685664
Name:BOURQUE, MARK SEVAN JR (PTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SEVAN
Last Name:BOURQUE
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 AZALEA RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-2859
Mailing Address - Country:US
Mailing Address - Phone:125-158-3165
Mailing Address - Fax:888-539-6550
Practice Address - Street 1:1220 AZALEA RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-2859
Practice Address - Country:US
Practice Address - Phone:125-158-3165
Practice Address - Fax:888-539-6550
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA9163225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant