Provider Demographics
NPI:1386815066
Name:BOURGAULT, RACHEL M
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:M
Last Name:BOURGAULT
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 1:2186 HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:BANNER
Mailing Address - State:WY
Mailing Address - Zip Code:82832-9709
Mailing Address - Country:US
Mailing Address - Phone:307-737-2274
Mailing Address - Fax:
Practice Address - Street 1:2186 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:BANNER
Practice Address - State:WY
Practice Address - Zip Code:82832-9709
Practice Address - Country:US
Practice Address - Phone:307-737-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY103235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist