Provider Demographics
NPI:1184221426
Name:BOURSIQUOT, MILENA (MA)
Entity Type:Individual
Prefix:
First Name:MILENA
Middle Name:
Last Name:BOURSIQUOT
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 1:45 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3405
Mailing Address - Country:US
Mailing Address - Phone:201-450-8074
Mailing Address - Fax:
Practice Address - Street 1:240 WALTON STE 2N
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:646-760-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health