Provider Demographics
NPI:1144426990
Name:BOURGOYNE, DEBRA BROWN (OT)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:BROWN
Last Name:BOURGOYNE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-7844
Mailing Address - Country:US
Mailing Address - Phone:225-343-4232
Mailing Address - Fax:225-343-4233
Practice Address - Street 1:535 W ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-7844
Practice Address - Country:US
Practice Address - Phone:225-343-4232
Practice Address - Fax:225-343-4233
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10549171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1302546Medicaid