Provider Demographics
NPI:1477941011
Name:BOURQUE, JOHN (LBSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:JOHN
Other - Last Name:BOURQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LBSW
Mailing Address - Street 1:34807 PHYLLIS ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2422
Mailing Address - Country:US
Mailing Address - Phone:734-722-1000
Mailing Address - Fax:734-722-0368
Practice Address - Street 1:35000 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2458
Practice Address - Country:US
Practice Address - Phone:734-722-1000
Practice Address - Fax:734-722-0368
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802060309104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker