Provider Demographics
NPI:1629370820
Name:BOURQUE, NANCY ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANNE
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 RIVERSIDE DR
Mailing Address - Street 2:#2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6156
Mailing Address - Country:US
Mailing Address - Phone:212-865-4176
Mailing Address - Fax:212-865-4176
Practice Address - Street 1:258 RIVERSIDE DR
Practice Address - Street 2:#2A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6156
Practice Address - Country:US
Practice Address - Phone:212-865-4176
Practice Address - Fax:212-865-4176
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0774381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical