Healthcare Provider Details

I. General information

NPI: 1669889325
Provider Name (Legal Business Name): CHARLA LARISSA BOURANIS ME.D, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 LINCOLN HOUSE PT
SWAMPSCOTT MA
01907-2707
US

IV. Provider business mailing address

19 LINCOLN HOUSE PT
SWAMPSCOTT MA
01907-2707
US

V. Phone/Fax

Practice location:
  • Phone: 781-854-1515
  • Fax:
Mailing address:
  • Phone: 781-854-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1966
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: