Provider Demographics
NPI:1407225923
Name:BOURGEOIS, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BOURGEOIS
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 1:4711 W CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GREENBUSH
Mailing Address - State:MI
Mailing Address - Zip Code:48738-9717
Mailing Address - Country:US
Mailing Address - Phone:989-254-2579
Mailing Address - Fax:
Practice Address - Street 1:4711 W CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:GREENBUSH
Practice Address - State:MI
Practice Address - Zip Code:48738-9717
Practice Address - Country:US
Practice Address - Phone:989-254-2579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI0-23-14327106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other