Provider Demographics
NPI:1326602822
Name:BOURQUE, KENNETH STEPHEN (CDPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:STEPHEN
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 CONCORDIA LN SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2150
Mailing Address - Country:US
Mailing Address - Phone:360-350-2082
Mailing Address - Fax:
Practice Address - Street 1:5915 ORCHARD ST W
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98467-3824
Practice Address - Country:US
Practice Address - Phone:253-414-7461
Practice Address - Fax:253-627-8387
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60833994101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60833994OtherWASHINGTON STATE DEPARTMENT OF HEALTH