Provider Demographics
NPI:1326403445
Name:BOURQUE, MARY (MOT, LOTR)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:MOT, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 JOHNSON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3640
Mailing Address - Country:US
Mailing Address - Phone:337-824-4547
Mailing Address - Fax:337-824-4548
Practice Address - Street 1:204 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4009
Practice Address - Country:US
Practice Address - Phone:337-896-6686
Practice Address - Fax:337-565-6003
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist