Provider Demographics
NPI:1679831143
Name:BOURGEOIS, DARYL PATRICK (MS, OTR/L)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:PATRICK
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-9105
Mailing Address - Country:US
Mailing Address - Phone:252-259-2012
Mailing Address - Fax:
Practice Address - Street 1:554 SECOND STREET
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513-7202
Practice Address - Country:US
Practice Address - Phone:252-714-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7220225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist