Provider Demographics
NPI:1457987885
Name:BOUSQUET, HEATHER (LMSW)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:BOUSQUET
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 HARBINS PASS DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7029
Mailing Address - Country:US
Mailing Address - Phone:678-983-0628
Mailing Address - Fax:
Practice Address - Street 1:1435 HAW CREEK CIR STE 403
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6567
Practice Address - Country:US
Practice Address - Phone:678-590-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0093441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty