Provider Demographics
NPI:1134507494
Name:BOURQUIN, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BOURQUIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12831
Mailing Address - Country:US
Mailing Address - Phone:518-746-1499
Mailing Address - Fax:518-747-8806
Practice Address - Street 1:77 MAIN ST
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839-2213
Practice Address - Country:US
Practice Address - Phone:518-746-1499
Practice Address - Fax:518-747-8806
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY0788921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical