Provider Demographics
NPI:1033820139
Name:BOURGETTE, KIM A (MA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:BOURGETTE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19550 SCOTER LN NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6545
Mailing Address - Country:US
Mailing Address - Phone:208-720-6593
Mailing Address - Fax:
Practice Address - Street 1:19550 SCOTER LN NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6545
Practice Address - Country:US
Practice Address - Phone:208-720-6593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61028132101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health