Provider Demographics
NPI:1801475553
Name:BOURG, ASHLEY NICOLE (LCSW-S)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:BOURG
Suffix:
Gender:F
Credentials:LCSW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 LONGWOOD GLEN LN
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-1502
Mailing Address - Country:US
Mailing Address - Phone:281-455-1031
Mailing Address - Fax:
Practice Address - Street 1:2002 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4211
Practice Address - Country:US
Practice Address - Phone:281-455-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX525611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9999999Medicaid