Provider Demographics
NPI:1780001289
Name:BOURQUE, GABRIELA
Entity Type:Individual
Prefix:
First Name:GABRIELA
Middle Name:
Last Name:BOURQUE
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 1:186 MARTIN LN
Mailing Address - Street 2:
Mailing Address - City:DES ALLEMANDS
Mailing Address - State:LA
Mailing Address - Zip Code:70030-4127
Mailing Address - Country:US
Mailing Address - Phone:504-858-6320
Mailing Address - Fax:
Practice Address - Street 1:2626 CHARLES DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-3779
Practice Address - Country:US
Practice Address - Phone:504-278-4006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor