Provider Demographics
NPI:1831643311
Name:BOURGEOIS, KRISTI
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:BOURGEOIS
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 1:1979 BEAUMONT DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1410
Mailing Address - Country:US
Mailing Address - Phone:225-928-1400
Mailing Address - Fax:225-928-1656
Practice Address - Street 1:855 SAINT FERDINAND ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-6453
Practice Address - Country:US
Practice Address - Phone:225-336-0000
Practice Address - Fax:225-336-0522
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1823101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600747398Medicaid