Provider Demographics
NPI:1720609019
Name:BOURGEOIS, BREANNE
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 W OWEN K GARRIOTT RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1814 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5525
Practice Address - Country:US
Practice Address - Phone:580-823-8017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty