Provider Demographics
NPI:1356850960
Name:BOURQUE, COTY (LCSW)
Entity type:Individual
Prefix:
First Name:COTY
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-1066
Mailing Address - Country:US
Mailing Address - Phone:337-519-7797
Mailing Address - Fax:
Practice Address - Street 1:1911 MISSION 66 STE B
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3762
Practice Address - Country:US
Practice Address - Phone:337-519-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health