Provider Demographics
NPI:1235579988
Name:BOURGEOIS, DOROTHY ELEANOR (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ELEANOR
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N DAVIS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6826
Mailing Address - Country:US
Mailing Address - Phone:904-355-3403
Mailing Address - Fax:904-355-4149
Practice Address - Street 1:1010 N DAVIS ST STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6826
Practice Address - Country:US
Practice Address - Phone:904-355-3403
Practice Address - Fax:904-355-4149
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 10212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist