Provider Demographics
NPI:1790234912
Name:BOURGEOIS, MARISHA (MS,MA)
Entity Type:Individual
Prefix:
First Name:MARISHA
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:MS,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 B ST
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1533
Mailing Address - Country:US
Mailing Address - Phone:504-952-2178
Mailing Address - Fax:
Practice Address - Street 1:9109 MENDENHALL MALL RD
Practice Address - Street 2:SUITE 5K
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7136
Practice Address - Country:US
Practice Address - Phone:504-952-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK473235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist