Provider Demographics
NPI:1609182195
Name:BOURGOYNE, MERRILL LYNN
Entity Type:Individual
Prefix:
First Name:MERRILL
Middle Name:LYNN
Last Name:BOURGOYNE
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 1:1014 WALLA WALLA AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1523
Mailing Address - Country:US
Mailing Address - Phone:509-663-0034
Mailing Address - Fax:
Practice Address - Street 1:1014 WALLA WALLA AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1523
Practice Address - Country:US
Practice Address - Phone:509-663-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health