Provider Demographics
NPI:1679695167
Name:BOURGEAULT, LISA C (BA, CASAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:BOURGEAULT
Suffix:
Gender:F
Credentials:BA, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-3207
Mailing Address - Fax:518-926-3215
Practice Address - Street 1:10 HARLEM ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-2934
Practice Address - Country:US
Practice Address - Phone:518-926-7200
Practice Address - Fax:518-926-7036
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4976101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)