Provider Demographics
NPI:1265736730
Name:BOURQUE, KRISTEN LEANNE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:LEANNE
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2785
Mailing Address - Country:US
Mailing Address - Phone:401-826-6695
Mailing Address - Fax:
Practice Address - Street 1:22 FRONT ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-4302
Practice Address - Country:US
Practice Address - Phone:508-676-1307
Practice Address - Fax:508-674-4493
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW01365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)