Provider Demographics
NPI:1629126958
Name:BOURGEOIS, ROSE (LMFT)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32797 NW PEAK RD
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-3035
Mailing Address - Country:US
Mailing Address - Phone:503-543-3558
Mailing Address - Fax:
Practice Address - Street 1:33555 E COLUMBIA AVE
Practice Address - Street 2:SUITE 214A
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-3436
Practice Address - Country:US
Practice Address - Phone:503-543-3558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0327106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist