Provider Demographics
NPI:1851499925
Name:BOURG, SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:BOURG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 E GLENN AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-4818
Mailing Address - Country:US
Mailing Address - Phone:334-821-3350
Mailing Address - Fax:334-821-3252
Practice Address - Street 1:248 E GLENN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-4818
Practice Address - Country:US
Practice Address - Phone:334-821-3350
Practice Address - Fax:334-821-3252
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1166103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51509821OtherBCBS