Provider Demographics
NPI:1023599297
Name:BOURGEOIS, GRETCHEN SMITH (SLP)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:SMITH
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BUTTERNUT LN
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-1097
Mailing Address - Country:US
Mailing Address - Phone:504-236-0473
Mailing Address - Fax:
Practice Address - Street 1:1011 N CAUSEWAY BLVD STE 25
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3282
Practice Address - Country:US
Practice Address - Phone:985-626-8403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist