Provider Demographics
NPI:1265846778
Name:BOURGEOIS LLC
Entity Type:Organization
Organization Name:BOURGEOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:203-770-1414
Mailing Address - Street 1:270 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-3407
Mailing Address - Country:US
Mailing Address - Phone:203-725-5042
Mailing Address - Fax:
Practice Address - Street 1:43 SHERMAN HILL RD
Practice Address - Street 2:CORNERSTONE PROFESSIONAL PARK, BUILDING D
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3651
Practice Address - Country:US
Practice Address - Phone:203-770-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002514101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00805070702Medicaid