Basic Information
| Provider Information | |||||||||
| NPI: | 1649612581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOUGOUKALOS | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 163 N MARENGO AVE | ||||||||
| Address2: | #402 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911014509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094854358 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4733 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237834011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT40326 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.