Provider Demographics
NPI:1447740337
Name:BOURGEAU, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:BOURGEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3595 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4027
Mailing Address - Country:US
Mailing Address - Phone:561-357-7779
Mailing Address - Fax:561-357-7796
Practice Address - Street 1:3595 2ND AVE N
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-4027
Practice Address - Country:US
Practice Address - Phone:561-357-7779
Practice Address - Fax:561-357-7796
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician