Provider Demographics
NPI:1114146859
Name:BOURGEOIS, LARISA (SLP)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 GALLOWAY LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-4675
Mailing Address - Country:US
Mailing Address - Phone:512-784-5669
Mailing Address - Fax:
Practice Address - Street 1:305 GALLOWAY LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-4675
Practice Address - Country:US
Practice Address - Phone:512-784-5669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist