| Doctor Name: | DR. MAMAWAH ISATA BOURQUE |
| NPI Number: | 1053659649 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | P.T. |
| License Number: | 1210663 |
| Business Practice Address: | 14332 Montfort Dr #4101 Dallas, TX - 752548486 |
| Business Phone Number: | 7132564708 |
| Business Fax Number: | |
| Mailing Address: | 14332 Montfort Dr, #4101 DALLAS |
| State: | TX |
| Postal Code: | 752548486 |
| Phone Number: | 7132564708 |
| Fax Number: | |
| NPI Enumeration Date: | 01/16/2013 |
| NPI Last Update Date: | 01/16/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 1210663 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |