Provider Demographics
NPI:1043353113
Name:BOURGET, MONA SHIZU (MA)
Entity Type:Individual
Prefix:MRS
First Name:MONA
Middle Name:SHIZU
Last Name:BOURGET
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 1:1679 EAST MAIN STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021
Mailing Address - Country:US
Mailing Address - Phone:619-441-1907
Mailing Address - Fax:619-441-1908
Practice Address - Street 1:1679 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5212
Practice Address - Country:US
Practice Address - Phone:619-441-1907
Practice Address - Fax:619-441-1908
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 53156106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist