Provider Demographics
NPI:1508696063
Name:BOURGERIE, MICHELLE M (AMFT & APCC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BOURGERIE
Suffix:
Gender:F
Credentials:AMFT & APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 AMBROSIA LN APT 1628
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-2624
Mailing Address - Country:US
Mailing Address - Phone:612-840-1184
Mailing Address - Fax:
Practice Address - Street 1:2011 PALOMAR AIRPORT RD STE 205
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1431
Practice Address - Country:US
Practice Address - Phone:760-334-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CAAMFT146456106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional