Provider Demographics
NPI:1780497115
Name:BOURGEOIS, BROOKE RENAE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:RENAE
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 1:1037 FOX SPARROW LOOP
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3041
Mailing Address - Country:US
Mailing Address - Phone:985-855-8621
Mailing Address - Fax:
Practice Address - Street 1:1202 S TYLER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2330
Practice Address - Country:US
Practice Address - Phone:985-898-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA330281225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist