Provider Demographics
NPI:1568196319
Name:BOURDEAU, TERI LYNN (CASAC-ADVANCED)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:LYNN
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:CASAC-ADVANCED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944-3619
Mailing Address - Country:US
Mailing Address - Phone:518-834-5550
Mailing Address - Fax:518-834-5557
Practice Address - Street 1:1703 FRONT ST
Practice Address - Street 2:
Practice Address - City:KEESEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-3619
Practice Address - Country:US
Practice Address - Phone:518-834-5550
Practice Address - Fax:518-834-5557
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34012101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)