Provider Demographics
NPI:1891115366
Name:BOURBEAU, STACEY (BSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BOURBEAU
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ERIN
Other - Last Name:BOURBEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:391 VARNUM AVENUE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:978-322-5095
Mailing Address - Fax:978-322-5097
Practice Address - Street 1:391 VARNUM AVENUE LOWER LEVEL
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-322-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health