Provider Demographics
NPI:1114141306
Name:BOURGUET-JIO, MICHELLE RENEE (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:BOURGUET-JIO
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 TWISTED BRANCH ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-0002
Mailing Address - Country:US
Mailing Address - Phone:505-345-1619
Mailing Address - Fax:
Practice Address - Street 1:I-40 WEST EXIT 114 TRAVEL RD 55
Practice Address - Street 2:
Practice Address - City:LAGUNA
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-552-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96551828Medicaid