Provider Demographics
NPI:1821472770
Name:BOURQUE, MELISSA R (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:R
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:141 E MAIN ST FL 4
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:141 E MAIN ST FL 1
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-574-9000
Practice Address - Fax:203-574-9006
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT102191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CTNOT ELIGIBLEOtherMHN TRICARE NORTH
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CTD339209OtherVALUE OPTIONS/BEACON HEALTH STRATEGIES
CTPENDINGOtherAETNA BEHAVIORAL HEALTH
CT060669107OtherUBH-UNITED HEALTH CARE WELLMORE GRP/FACILITY
CT060669107OtherUBH-OXFORD HEALTH FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CT13671798OtherCAQH
CT008062581Medicaid
CT060669107OtherUNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CT060669107OtherUBH-OXFORD HEALTH FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CT060669107OtherUBH-OXFORD HEALTH FREEDOM/LIBERTY WELLMORE GRP/FACILITY