Provider Demographics
NPI:1821068388
Name:BOURQUE, MAUREEN M (PT)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:M
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 FUNDY RD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1704
Mailing Address - Country:US
Mailing Address - Phone:207-781-8358
Mailing Address - Fax:207-781-8357
Practice Address - Street 1:5 FUNDY RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1704
Practice Address - Country:US
Practice Address - Phone:207-781-8358
Practice Address - Fax:207-781-8357
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME115227174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME11538314OtherCAQH