Provider Demographics
NPI:1962507293
Name:BOURG, CAROLYN JO (LCSW-BCD)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:JO
Last Name:BOURG
Suffix:
Gender:F
Credentials:LCSW-BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-7607
Mailing Address - Country:US
Mailing Address - Phone:409-724-1920
Mailing Address - Fax:
Practice Address - Street 1:3005 AVENUE H
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-7607
Practice Address - Country:US
Practice Address - Phone:409-724-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81501WMedicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER