Provider Demographics
NPI:1225729833
Name:BOURGEOIS, SHELBY LEANN
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEANN
Last Name:BOURGEOIS
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 1:949 E ESTATES BLVD APT 306
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5669
Mailing Address - Country:US
Mailing Address - Phone:864-345-5967
Mailing Address - Fax:
Practice Address - Street 1:328 GLEN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-4653
Practice Address - Country:US
Practice Address - Phone:843-460-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician